The  Radical  Cure  of  Hernia 


G    000  005  615    0 


By  Henry  O.  Marcy,  A.  M.,  M.  D.,  LI 


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PEPTONISED  MILK. 

(FAIRCHILD     PROCESS.) 

The  Ideal  Food  for  the  sick,  the  delicate,  the  con- 
sumptive, the  habitual  dyspeptic,  the  diabetic. 


Peptonised  MDk  is  milk  in  which  the 
caseine  has  been  wholly  or  partially 
converted  into  peptone,  the  degree  of 
this  conversion  to  be  controlled  at  will, 
as  determined  by  the  needs  of  the  case. 
All  the  other  elements  of  the  milk,  the 
sugar,  fat  and  mineral  salts,  are  already 
provided  by  nature  in  a  condition  for 
perfect  assimilation,  loithout  digestive 
effort. 

One  pint  op  Milk.,  when  peptonised, 
contains  two  ounces  of  total  dry 
SOLIDS— Milk  Peptones,  Milk  Sugar, 
Fat  and  Ash. 

Of  Beef  Tea,  Dr.  Christison  says:    I 
"  He  was  able  to  obtain  but  a  quarter 
"of  an  ounce   of  solid   residue  in  a 
"pint:'  ; 


This  solid  residue  consists  of ' 
"  the  trifling  amount  of  proteid  mater- 
"ial  and  of  fat  (which  latter,  in  prac- 
"  tice,  is  guarded  against  with  great 
"  care),  only  the  salts  of  the  muscle,  the 
"  hematin,  and  allied  pigments,  traces 
"of  sugar,  perhaps,  some  lactic  acid, 
"  and  the  nitrogenous  extractives  crea- 
' '  tin  and  its  congeners .  As  the  original 
"half  pound  of  muscle  'may  contain 
"about   forty   to   sixty  grains  of  the 


"salts,  and  ten  to  twelve  grains  of  the 
"  nitrogenous  waste  products,  the  beef 
"tea  (half  pint)  certainly  contained  no 
"more."— Prof.  Baumgarten. 

Of  Beef  Extract,  Dr.  Pavy  says: 
"There  are  grounds  for  believing  that 
"  a  considerable  proportion  consists  of 
"products  of  proteid  decay,  materials 
"in  course  of  retrograde  metamorpho- 
"sis,  that  are  of  no  use  as  nutritive 
"agents."  • 

The  well  nigh  superstitious  ideas  en- 
tertained by  the  laity  of  beef  tea,  is 
expressed  in  the  allusion  to  the 
"strength''  which  is  popularly  sup- 
posed to  be  extracted  in  the  tea;  after 
which  the  beef  is  thrown  to  the  dogs. 
The  working  man  makes  soup  from  a 
joint  and  consumes  the  "  strength  "  and 
the  beef  both . 

The  medical  profession  insist  that 
patients  shall  profit  by  the  knowledge 
and  progress  of  medical  science,  by  the 
use  of  artificially  digested  fresh  milk, 
etc.  The  Nostrum  advertisers  usurp 
functions  of  the  physician  by  prescrib- 
ing fictitious  "  foods  for  invalids,"  foods 
which  medical  science  has  long  since 
condemned. 


PEPTONISING   TUBES 


In  boxes  of  1  dozen  tubes,  at  50  cents  retail 
milk. 

Pamphlets  and  samples  gratis  to  physicians, 


Each  tube  peptonises  one  pint  of 


FslIRCHILD  BROS.  «fe  FOSTER, 

82  8<  84  FULTON  STREET    NEW  YORK. 


A  TREATISE  0^  HERNIA. 

THE  RADICAL  CURE 


BY  THE  USE  OF  THE 


BURIED  ANTISEPTIC /NIMAL  SUTURE, 


HENRY  O.  MARCY,  A.  M.,  M.  D.,  LL.  D., 

OF    BOSTON,  MASS. 

Surgeon  to  the  Private  Hospital  for  Women,  Cambridge;  President  of  the 
Section  of  Gynecology^   Ninth  International  Congress;  late  President 
of  the  American  Academy   of  Medicine;  Member   of  the    British 
Medical  Association;  Member   of  thi   Mass  ichusetts   Medical 
Society;  Fellow  Boston  Gynecological  Society;  Correspond- 
ing    Member     of  the    Medico-Chirurgical  Society    of 
~  lognz,  Italy;  Member  of  the  American  Associa- 
tion of  Obstetricians  and  Gynecologists:  late 
Surgeon   U.  S.  Army,  etc.,  etc. 


GEORGE    S.  DA.VIS, 

DETROIT,    MICH. 


Copyrighted  by 
GEORGE   S.   DAVIS. 


PREFACE. 


This  little  book  is  offered  the  profession,  as  the  outgrowth 
of  special  studies  upon  the  subject  of  Hernia  for  the  last 
eighteen  years.  In  1S70  the  author  first  operated  for  the  radi- 
cal  cure  of  hernia  by  the  open  wound  method,  and  the  closure 
of  the  parts  by  the  use  of  the  buried  animal  suture.  Based 
upon  a  series  of  experimental  studies  upon  animals,  under- 
taken  for  the  purpose,  it  was  believed  to  be  demonstrated  that 
aseptically  applied  animal  sutures  became  so  incorporated  into 
the  vital  structures  as  to  be,  in  large  measure,  replaced  by 
connective  tissue.  The  result  of  these  investigations  taught 
that  the  application  of  animal  sutures,  for  the  cure  of  hernia, 
is  clearly  of  the  first  importance.  Convinced  that  my  own  ex- 
perience has  demonstrated  the  truth  of  these  opinions,  I  have 
taken  pleasure  in  adding  thereto,  as  far  as  possible,  the  views 
of  modern  surgeons,  which  I  offer  in  the  belief  that  the  data  is 
now  quite  sufficient  to  settle,  with  comparative  accuracy,  the 
question  of  operative  measures  for  the  cure  of  hernia,  con- 
fessedly hitherto  an  opprobrium  of  surgery.  If  the  teaching 
thus  formulated  shall  guide  to  better  results,  and  aid  in  placing 
measures  undertaken  for  the  cure  of  hernia  upon  a  more  estab- 
lished basis,  the  purpose  for  which  this  work  was  undertaken 
will  have  been  accomplished.  I  am  indebted  to  Dr.  Joseph  H. 
Warren,  of  Boston,  for  the  loan  of  several  electrotypes. 

Henry  O.  Marcy. 

116  Boylston  St.,  Boston,  i88q. 


CONTENTS. 


CHAPTER  I. 
General  Considerations  on  Hernia. 


PAGES. 


Definition  of  Hernia — Classification — Frequency  as  to 
Age,  Sex,  and  Occupation— Baxter's  and  King- 
don's  Tables — Causation — Congenital  Hernia — 
Changes  in  Hernial  Sac— Inguinal  Hernia,  Com- 
plete and  Incomplete 1-13 

CHAPTER  II. 

Formation  of  Hernial  Sac. 

Peritoneal  Covering — Description  of  and  Pathological 
Changes  in  the  Peritoneum — Development  of  In- 
guinal Canal — Formation  of  Sac  in  Congenital 
Hernia — Encysted  Hernia — Pathological  Changes 
in  Hernial  Sac 14-31 

CHAPTER   III. 

Anatomy — Descriptive  and  Surgical. 

Anatomical  Relations  in  Inguinal  Hernia — Spermatic 
Vessels  and  Cord — Boundaries  of  Inguinal  Canal 
—Oblique  Inguinal  Hernia— Contents  of  Inguinal 
Hernia — Reducible  Inguinal  Hernia 32-53 

CHAPTER  IV. 

Instrumental  Supports. 

Trusses,  French,  English,  American,  Application  of.  .        54-58 


VI. 

PAGES. 

CHAPTER  V. 

Irreducible  and  Strangulated  Hernia. 

Irreducible,  Symptoms  of — Strangulated,  Pathological 
Factorage  — Contents — Omental — Intestinal — Im- 
portance of  Early  Diagnosis  and  Prompt  Relief.  .       59-71 

CHAPTER  VI. 

Surgical  Procedures. 

Operative  Measures  in  General — Instruments  Required 
in  Herniotomy —Details  of  Operation — Treatment 
of  the  Wound  after  Reduction  of  the  Strangulated 
Parts — Advantages  of  Resection  of  the  Sac 72-88 

CHAPTER  VII. 

Femoral    Hernia. 
Anatomy    of    Parts    Involved    in — Contents    of — Re- 
cognition of  Femoral  Hernia — Operative  Measures 
in  Femoral  Hernia — Author's  Operation — Wood's 
Operation 79-1 12 

CHAPTER    VIII. 
Obturator  Hernia. 
Anatomy  and  Contents  of — Ischiatic  Hernia — Umbili- 
cal Hernia — Operation  in  Strangulated  Umbilical 
Hernia 1 13-127 

CHAPTER    IX. 

The  Radical  Cure  of  Hernia. 
History  of  the  Various  Methods  of  Treatment — Caustic 
— Punctum  Aureum,  Royal  Stitch — Langenbeck's 
Method — Gerdy's  Method — Use  of  Seton — Injec- 
tion of  Iodine — Dr.  Warren's  Modification  of  the 
Heaton  Method  —  Wood's  Method  —  Dowell's 
Method 128-164 


VII. 

PAGES. 

CHAPTER  X. 

Radical  Cure  of  Hernia  by    the    Open     Wound  Method  Unde* 
Antiseptic  Precaution. 

History  of  Animal  Sutures  —  Advantages  of  the 
Author's  Method  of  Operation  by  the  Use  of  the 
Buried  Tendon  Suture — Review  of  the  Open 
Wound  Methods  Employed  in  Europe  —  Prof. 
Socin's — Mr.  Bank's — Mr.  Frank's — Mr.  Ball's — 
Mr.  Macewen's — The  Open  Wound  Treatment  in 
America 165-213 

CHAPTER  XI 

Conditions  Rendering  Operative  Measures  Advisable. 

In  Children — In  Adults 214-225 

CHAPTER  Xn. 

Method  of  Operation  Advised. 

Open  Dissection  Method — When  to  Operate  in  Fe- 
moral Hernia — Umbilical  Hernia — Advantages  of 
Open  Wound  Treatment — The  Sac— Reconstruc- 
tion of  Canal  by  Buried  Animal  Suture — Treat- 
ment of  Wound 226-238 


CHAPTER  I. 

DESCRIPTIVE. 

Hernia  may  be  defined  as  the  portion  of  the  con- 
tents of  any  cavity  projecting  through  an  opening  in 
its  walls.  However,  surgically  considered,  unless 
otherwise  stated,  the  term  is  usually  restricted  to  the 
abdomen. 

Abdominal  hernias  are  remarkable  for  their  fre- 
quency, variety,  and  the  danger  attending  them. 
They  are  produced  by  the  protrusion  of  the  viscera, 
contained  in  the  abdomen,  through  the  natural  or 
accidental  apertures,  in  the  parietes  of  that  cavity. 
The  organs  which  form  them  most  frequently  are  in- 
testines and  omentum. 

Herniae  have  been  divided,  according  to  the 
aperture  by  which  they  escape,  into: 

I.  Inguinal  or  siipra-pubian  herniiE.  These  issue 
by  the  inguinal  canal;  they  are  called  bubonocele 
when  small,  especially  when  concealed  by  escape  into, 
rather  than  completely  through  the  parietal  wall; 
scrotal  herniae,  when  they  descend  into  the  scrotum  in 
the  male:  vulvar  or  pudendal  herniae  in  the  woman 
when  they  extend  to  the  labia  majora. 

n.  Crurai,  or  femoral  hernicE,  when  they  issue  by 
the  femoral  canal. 

in.  Infra-pubian  hernm,  when  the  viscera  escape 
through  the  openin^^  which  gives  exit  to  the  infra- 
pubian  vessels,  hernia  forannnis  cvulis. 


IV.  Ischiatic  hernia,  when  it  takes  place  through 
the  sacro-sciatic  notch. 

V.  Umbilical  hernia,  when  it  takes  place  at  or 
near  the  umbilicus. 

VI.  Epi- a7td  hypogastric  hernice,  wfhQn  they  take 
place  above  or  below  the  umbilicus  in  the  linea-alba. 

VII.  Pe7'ineal  hernia,  when  it  occurs  through  the 
levator  ani  and  appears  at  the  perineum. 

VIII.  Vaginal  hei^nia,  when  through  the  parietes 
of  the  vagina. 

IX.  Diaphragmatic  hernia,  when  it  escapes 
through  the  diaphragm. 

Herniae  are  likewise  distinguished  by  their  con- 
tents, as  enterocele,  epiplocele,  etc. 

Herniae  are  also  described  as  old  or  recent,  and 
reducible  or  irreducible,  incarcerated,  strangulated, 
etc. 

Abdominal  herniae  are  of  very  frequent  occur- 
rence, owing  to  the  mobility  and  varying  bulk  of  the 
viscera,  the  pressure  which  they  experience,  in  all  con- 
siderable efforts  and  motions  of  the  body,  from  the 
muscles  which  in  great  part  surround  and  enclose 
them;  and  the  natural  openings  of  the  cavity  are  cir- 
cumstances greatly  facilitating  the  origin  of  such  mis- 
placements. 

The  importance  of  any  given  hernia  is  dependent 
upon  the  contents,  the  pressure  exerted,  and  especially 
the  impairment  of  intestinal  function  which  may  in- 
directly arise  when  the  intestinal  canal  itself  is  not  in- 


eluded.  When  intestinal  obstruetion  occurs,  from  any 
cause,  life  is  imperiled,  almost  in  a  geometric  ratio  to 
its  duration,  a  fact  which  cannot  be  too  greatly  em- 
phasized. 

The  frequency  of  hernise  is  quite  greater  than 
usually  supposed.  It  has  been  variously  estimated  by 
surgeons  of  great  experience,  in  the  treatment  of  rup- 
tures, that  from  one-eighth  to  one-sixteenth  of  the 
human  race-  is  afflicted  with  this  complaint. 

From  the  elaborate  tables  of  Dr.  J.  H.  Baxter, 
Surgeon  U.  S.  A.,  we  learn  that  the  results  of  the  ex- 
amination of  334,321  ''recruits,  substitutes,  drafted 
and  enrolled  men  of  various  nativities,"  gave  hernia  as 
the  cause  of  rejection  in  17,296  cases,  as  seen  in  the 
following  table: 


DISEASE. 


NUMBER 

RATIO 

REJECTED. 

REJECTED. 

651 

328 
8,598 

1,947 

0,948 
0,981 
25,7.8 

5,420 
1.166 

I0,2T2 
3,488 

277 

0,829 

119 

0,329 

34 

0,t02 

17,296 

50,554 

Hernia,  kind  not  specified. 

Hernia,  umbilical , 

Hernia,  ventral 

Hernia,  rigrht  inguinal 

Hernia,  left  inguinal 

Hernia,  double  inguinal... 

Hernia,  right  femoral , 

Hernia,  left  femoral. .. ..    . 

Hernia,  double  femoral 


Total  for  hernia  of  all  kinds . 


"  From  this  statement,  it  appears  that  inguinal 
hernia  was  the  cause  of  about  eighty-two  per  centum 
of  all   rejections  on   account   of  hernia,  and  that  the 


cases  of  right  inguinal  hernia  exceeded  in  number  all 
the  rest.  Other  tables  confirm,  in  a  most  conclusive 
manner,  this  latter  indication,  to  wit:  that  inguinal 
hernia  of  the  right  side  is  far  more  prevalent  than  that 
of  the  left.  The  cases  of  umbilical  and  ventral  hernia 
were  about  equal,  but  inconsiderable  in  number  as 
compared  with  right  inguinal." 

If  we  accept  that  the  tables  of  Dr.  Baxter  afford 
any  criterion  of  frequency  of  hernia,  in  the  United 
States,  the  sum  total  of  the  individuals  afflicted  with 
hernia  is  not  less  than  three  millions. 

Since  the  tables  were  based  upon  the  examina- 
tion of  about  half  a  million  of  men,  within  the  limit  of 
age  to  bear  arms,  a  considerable  proportion  of  the 
same  presenting  themselves  to  be  examined  for  this 
purpose,  it  may  not  be  considered  as  an  excessive 
proportion  of  the  entire  population. 

Malgaigne  estimated  the  proportion  of  the  whole 
population  of  France,  which  is  ruptured,  to  be  one 
out  of  every  thirteen  males,  and  one  out  of  every 
fifty-two  females;  including  both  sexes,  one  in  every 
twenty  individuals. . 

Sex. — There  have  been  furnished  no  requisite  data 
for  comparison  of  the  relative  frequency  of  hernia  in 
the  two  sexes. 

Anatomically,  the  structures  favor  the  liability  of 
hernia  in  the  male;  the  more  violent  exercise  and 
severer  labors  of  the  male  are  also  predisposing 
causes.     It  is  generally  conceded  that   hernia  occurs 


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—  8  — 

more  frequently  in  the  male.  Out  of  a  gross  total  of 
96,886  applications  for  trusses  at  the  City  of  London 
Truss  Society,  the  males  were  78,394,  the  females 
18,492.  Several  authors  give  the  proportion  as  about 
double  in  the  male. 

Frequency  of  Hernia  at  Different  Ages. — Accord- 
ing to  M.  Malgaigne,  in  three  hundred  cases  examined 
by  himself: 

26  occurred  between  the  ages  of  10  and  20  years. 

45         *>  "  "  "  "    20     "  30 

66         "  "  "  "  "    30     "  40       " 

163         •'  "  "  "  "    40     "  80 

This  record  is,  however,  to  be  explained  by  the 
statement  that  the  ages  are  taken  from  the  entry  of 
the  visit  of  the  patient,  giving  his  age  then,  rather 
than  when  he  first  knew  the  disease  existed.  Mr. 
John  Croft  reports  a  table  of  2,401  cases  of  hernia,  of 
which  472  were  in  children,  under  five  years  of  age. 
Mr.  Kingdon,  in  the  reports  of  the  City  of  London 
Truss  Society  for  the  years  of  i860  and  1861,  tabulated 
9,296  cases  of  hernia.  Of  these  60.8  per  cent,  had 
commenced  before  35  years  of  age,  and  39.2  per  cent, 
after  that  age.  Of  the  whole  number,  2,516  were 
under  five  years  of  age. 

An  analysis  of  the  following  table  from  Mr.  King- 
don's  report  shows  that  the  percentage  of  herniae  in 
children  is  less  than  would  at  first  appear,  and  that, 
relatively,  hernia  is  more  common  after  35  than  be- 
fore this  age: 


—  9  — 


ST 

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KING 

REPC 

SOCIET 

AGE  AT 

don's  t/ 

RTS  OF  ' 

Y,  l86l  1 

DEVELC 

LBLES. 
FRUSS 

o  1862. 

)PMENT. 

Occupation. — It  is  generally  accepted  that  the 
laboring  classes  are  more  liable  to  hernia.  However, 
any  reliable  data  are  wanting  to  determine  this,  since 
all  statistics  from  our  large  public  institutions  are 
based  entirely  upon  the  application    of  those  whose 


»eedy  condition  demands,  in  a  measure,  a  public 
charity.  The  wealthier  classes  afford  no  opportunity 
for  statistical  knowledge.  However,  it  is  accepted 
that  the  general  imperfect  state  of  muscular  strength 
and  the  lax  condition  of  the  tissues,  dependent  upon 
sedentary  habits,  render  hernia  more  likely  to  super- 
vene suddenly  upon  violent  strain.  Under  such  con- 
ditions, it  is  well  known  herniae  are  very  common,  al- 
though a  feeling  of  reticence  makes  reference  to  such 
suffering  the  exception. 

Conditions.  -  Individuals  suffering  from  hernia  gen- 
erally complain  that  they  are  much  more  troubled  to  re- 
tain the  parts  in  position,  when  weakened  or  debilitated 
by  disease.  The  tissues  are  relaxed  and  less  able  to  sus- 
tain strain.  It  is  also  commonly  observed  that  per- 
sons, deficient  in  general  strength  and  tone,  as  age  ad- 
vances, become  more  subject  to  hernia.  There  is  an- 
other considerable  class,  in  both  sexes,  that,  after  the 
middle  period  of  life,  where  a  tendency  to  over-weight 
is  marked,  producing  an  increase  of  intra-abdominal 
pressure,  become  liable  to  hernia. 

From  infancy  to  old  age,  the  abdominal  cavity 
must  be  subject  to  daily  variations  in  size  and  con- 
tents. The  gaseous  ancj  fluid  distention  of  the  in- 
testinal canal  is  often  excessive;  the  omental  and 
parietal  fat  frequently  increases  with  great  rapidity, 
and  these  conditions,  of  necessity,  call  into  play  a  con- 
stant strain  upon  the  abdominal  supports  which  must 
be  elastic  and  accommodative  to  movement.     In  wo- 


—   II   — 

men,  the  results  of  over-distension  from  pregnancy, 
violent  muscular  effort  in  parturition,  a  lack  of  proper 
tone  and  vigor  of  the  parietal  structures  which  fre- 
quently ensues  upon  delivery,  must  also  be  considered 
as  causes  of  hernia,   especially  umbilical  and  ventral. 

If  individuals  vary  greatly  in  construction  and 
composition,  as  to  strength  and  firmness  of  their  tissues, 
it  seems  but  a  natural  consequence  that  such  condi- 
tions should  have  a  tendency  to  be  transmitted  to 
their  descendants  and,  as  will  be  seen  later,  congeni- 
tal hernia  is  very  common.  A  constitutional  weak- 
ness, especially  of  the  parietal  peritoneum  and  of  the 
mesenteric  ligament  has  been  advanced,  even  by  some 
of  our  prominent  writers  upon  the  subject,  as  a  cause 
of  hernia.  This  is  based  upon  the  assumption  that, 
otherwise,  the  small  intestines  could  not  be  dragged 
down  so  as  to  reach  below  the  rings  or  into  the  scrotum. 
My  experience,  in  laparotomy,  teaches  me  that  the 
small  mtestines,  are,  as  a  rule,  normally  quite  free  to 
be  carried  below  any  possible  escape  through  the  base 
of  the  pelvis. 

The  anatomical  relations  of  the  mesentery  to 
the  intestine  are  primarily,  less  those  of  support  than 
of  limitations  in  physiological  action.  The  vessels 
and  nerves  are  not  put  on  tension,  but  lie,  without 
strain,  with  a  certain,  of  necessity,  freedom  of  motion. 
Remove  the  supporting  power  of  the  abdominal  walls 
in  any  direction  and,  necessarily,  the  intestinal  con- 
tents   will   follow.      Were  it  otherwise,   either  a  con- 


12     

siderable  percentage  of  the  people  of  all  countries  are 
congenitally  malformed,  or  hernia  is  not  caused,  as 
commonly  attributed,  by  over-strain,  lifting,  coughing, 
or  any  violent  compression  of  the  abdominal  walls. 

It  is  very  probably  true  that  a  large  proportion  of 
the  so-called  immediate  ruptures  are  preceded  by  a 
train  of  _cau^esJeadjngj,;jg__totl^^  away,  at  last, 

suddenly  of  the  weakened  ring,  but  even  these  could 
not  increase  the  length  of  the  mesentery,  unless  first 
the  dimensions  of  the  abdominal  cavity  were  materially 
changed.  In  the  so-called  pendulous  belly  of  multi- 
parous  women,  the  intestines  easily  follow  to  the  very 
base,  when  the  patient  is  in  the  upright  posture,  but  I 
have  yet  to  learn  that  the  yielding  of  the  recti  muscles 
IS  supposed  to  be  caused  by  the  lengthening  of  the 
mesenteric  ligament. 

Constipation,  dysuria,  a  harassing  cough,  are 
aisc  airect,  as  well  as  remote,  causes  of  hernia.  It  is 
the  common  experience  of  the  ruptured, /toascrib^the 
cause  as  due  to  violent  muscular  exertion.  The  con- 
tents of  the  hernial  sac  are  those  portions  of  the  ab- 
dominal viscera  subject  to  the  widest  latitude  of  move- 
ment and  it  may  be  owing  to  this,  that  it  has  been 
assumed  necessary  to  have  first  an  elongated  mesen- 
teric attachment,  before  the  small  intestine  could  form 
a  part.  Owing  to  this  freedom  of  motion,  portions  of 
the  omentum  and  small  intestine,  in  the  great  majority 
of  instances,  form  the  contents,  although  portions  of 
every  abdominal  organ  have  occasionally  been  in- 
volved in  hernia. 


—    13   — 

When  the  large  intestine  is  involved,  the  part  pro- 
truded is,  generally,  either  the  coecum  or  the  sig- 
moid flexure  of  the  colon,  since  these  are  less  fixed 
than  other  portions  of  the  canal.  When  the  coecum, 
it  occurs  usually,  as  we  should  expect,  upon  the  right 
side;  when  the  sigmoid  flexure,  upon  the  left;  yet  cases 
of  the  opposite  are  on  record  and  also  where  both  the 
coecum  and  sigmoid  flexure  have  been  included  in  an 
omental ,  hernia.  In  fleshy  and  elderly  people,  the 
omentum  is  generally  heavily  loaded  with  fat,  and,  on 
this  account,  the  omentum  is  rendered  more  liable 
to  become  involved  in  hernia.  Cases  are  on 
record  where  the  bladder,  uterus,  ovaries,  spleen, 
stomach,  and  kidne}^  have  been  found  in  the  hernial 
sac. 

Herniaae  have  sometimes  been  classified  as 
external  and  internal — complete  or  incomplete. 
The  former,  when  the  abdominal  contents  protrude 
to  form  a  tumor,  obvious  upon  ordinary  inspec- 
tion; the  latter,  when  some  portion  of  the  abdominal 
viscera  is  so  displaced  as  to  impair  function,  as,  for 
example,  when  the  bowel  passes  through  an  opening 
in  the  diaphragm  or  into  some  cavity,  formed  by  peri- 
toneal folds,  or  confined  by  bands  of  adhesion.  All 
these  changes  are  properly  classified  in  a  general  work 
on  hernia  and  will  be  noticed,  at  some  length,  in  their 
proper  place.  They  are  often  attended  with  very 
grave  danger,  since  they  are  not  easy  to  define,  and 
may  as  surely  obstruct  the  intestinal  canal  as  when  it 
escapes  through  an  opening  externally. 


CHAPTER  II. 

Formation  of  sac. — Except  in  tfie  rarest  of  in- 
stances, the  hernial  contents  are  enclosed  in  a  por- 
tion of  the  parietal  peritoneum,  which  is  carried 
before  them,  and  this  constitutes  the  sac;  a  cavity 
continuous  with  that  of  the  abdomen.  At  the  out- 
set, the  size  of  the  cavity  is  limited  to  that  of  the 
opening,  which  has  generally  a  tendinous  and  com- 
paratively unyielding  border.  Over  the  opening,  how- 
ever, the  parts  are  usually  soft  and  weak,  often  loose 
fascia  and  integument,  and,  little  by  little,  the  peri- 
toneum stretches,  under  the  pressure,  into  a  bag  of 
greater  or  less  size  and  varying  in  shape,  but  com- 
municating with  its  origin  by  the  original  opening, 
often  not  much  changed,  called  the  mouth  or  neck  of 
the  sac;  the  peritoneum  at  the  mouth  of  the  sac  is  intra- 
folded  or  plicated.  When  the  contents  of  the  sac  can  be 
returned,  often  the  general  functions  go  on  unimpaired, 
the  subject  suffering  only  a  limited  weakness  and  incon- 
venience. Changes  of  vascularity  and  nutrition,  how- 
ever, generally  soon  ensue,  the  sac  becomes  thickened, 
adhesions  of  the  contents  follow,  and  a  general  in- 
crease of  bulk  takes  place.  So  long  as  the  contents 
of  the  sac  can  be  returned,  the  hernia  is  called  reducible. 
When  the  hernial  contents  can  no  longer  be  returned 
to  the  abdomen,  although  the  suffering  or  inconveni- 
ence is  not  extreme,  it  is  called  irreducible.  When 
from    pressure,  or    constriction,   the    function  of   the 


—  15  — 
contents  is  suspended,  the  hernia  is  then  incarcerated, 
or  strangulated,  and  the  narrow  surrounding  portion, 
usually  at  the  neck,  is  called  the  stricture.  The  exist- 
ence of  a  peritoneal  covering,  as  a  sac,  is  dependent 
upon  the  contents  of  the  hernia  being  made  up  of 
organs  within  the  abdomen  proper,  as  the  bladder 
could  protrude  entirely  from  below  the  peritoneal  re- 
flexion. Cystocele  and  rectocele,  in  a  sense,  are  also 
hernial  tumors,  but  without  a  peritoneal  investing 
membrane. 

Hernia  also  exists,  without  a  peritoneal  invest- 
ment, in  wounds;  e.g.  penetrating  wounds  of  the  ab- 
domen, but,  other  than  these,  the  peritoneum,  more  or 
less  altered,  is  constant  in  hernia,  as  the  chief  com- 
ponent of  the  sac.  The  definition,  earlier  given  to 
hernia  as  rupture,  was  dependent  upon  the  belief  that 
a  sudden  giving  way  of  the  enclosing  parts  generally 
included  also  an  actual  lesion  of  the  peritoneum. 
The  peritoneum  lines  the  cavity  of  the  abdomen  and 
is  reflected  over  all  the  organs  contained  in  it,  giving 
to  each  an  external  covering.  This  serous  membrane 
is  thin,  semi-transparent,  and  perfectly  smooth  on  its 
internal  surface  and  is  lubricated  by  a  fluid  which  not 
only  gives  it  a  polished  appearance,  but  permits  move- 
ment of  the  organs  upon  each  other  and  the  restrict- 
ing walls  without  friction.  The  texture  of  the  mem- 
brane is  of  connective  tissues,  disposed  in  obliquely 
crossing  layers  which  give  it  much  strength  and  yet 
renders  it  of  a  yielding   character;   this   is   farther  in- 


—   i6  — 

creased  by  elastic  tissue  entering  in  a  minor  degree, 
into  its  composition.  It  is  covered  with  a  squamous 
epithelium  and  is  very  rich  in  vessels,  nerves,  and 
lymphatics.  An  interesting  experiment  is  the  dissec- 
tion of  a  fresh  peritoneum  and  securing  it  tense,  like  a 
drum-head.  In  this  manner,  it  will  support  a  con- 
siderable weight  for  some  time  and,  upon  its  removal, 
return  to  its  original  shape.  If  longer  retained,  it  will 
relax  as  a  depressed  pouch,  and  a  careful  observation 
will  show  that  the  structure  has  yielded  by  an  irregu- 
lar separation  of  its  component  layers.  The  texture 
and  strength  not  only  differ  in  different  individuals, 
but  notably  in  different  parts  of  the  same  subject. 
Where  it  lines  the  abdominal  walls  it  is  thicker,  gray- 
ish white,  semi-opaque  and  nearly  conceals  the  color 
of  the  adjacent  parts;  over  the  mesentery,  on  the  con- 
trary, it  is  often  nearly  transparent.  To  the  linea- 
alba  and  the  sheath  of  the  recti  muscles,  the  peritoneum 
is  very  closely  adherent,  but  is  loosely  connected  to 
the  lateral  abdominal  parietes  by  a  thin  lamina  of  con- 
nective tissue.  Its  external  surface  is  often  rough 
and  irregular. 

Physiologically,  it  is  subject  to  extraordinary 
changes,  which  are  of  much  importance  viewed  from 
the  standpoint  of  our  present  study,  as  evinced  by  the 
ever-changing  peritoneal  investment  of  the  stomach, 
intestine,  bladder,  and  the  uterus  in  pregnancy;  also 
the  development  of  the  peritoneum  over  a  rapidly 
growing   ovarian  tumor,  or  the  distension  of  the  ab- 


—  17  — 

dominal  wall,  to  several  times  its  original  surface  in 
abdominal  drospy.  After  such  pathological  changes, 
the  peritoneum  is  frequently  restored  to  its  former 
normal  state.  In  cases  of  sudden,  forcible  distension, 
particularly  where  the  membrane  is  thin  and  adheres 
closely  to  the  abdominal  parietes,  or  other  surround- 
ing parts,  its  texture  yields  partially  and  undergoes  a 
loosening,  or  species  of  laceration,  such  as  in  the  case 
of  silks  or  other  stuffs  we  call  fraying,  the  French 
eraillment,  a  kind  of  cicatrization  follows,  and  leaves 
marks  or  lines  behind,  indicating  the  nature  of  the 
occurrence:  ''These  eraillments,"  says  M.  J.  Cloquet, 
"  happen  particularly  when  peritoneum,  adhering  to 
subjacent  parts  by  a  dense,  close,  cellular  tissue,  is 
dragged  or  displaced.  Hence  this  partial  laceration  is 
frequent  in  the  situation  of  the  linea  alba,  from  the  dis-- 
tension  of  the  abdomen  and  the  separation  of  the  recti 
muscles;  and  I  possess  several  remarkable  specimens- 
of  this  kind.  In  the  part  which  has  been  thus  frayed,, 
the  peritoneum  is  preternaturally  thm,  representing  a 
net-work  of  slender  fibres,  leaving  irregular  inter- 
spaces, which  are  filled  by  an  extremely  thin,  trans- 
parent pellicle.  This  kind  of  change  is  observed,  not 
only  in  the  peritoneum  lining  the  abdominal  parietes, 
and  that  which  forms  the  hernial  sac,  where  it  is  very 
common,  but  also  in  the  serous  covering  of  the  dis- 
placed viscera,  in  the  mesentery  and  intestine  when 
they  have  been  dragged  and  elongated  in  large  rup- 
tures."— [Recherches'  Anat.,  p.  48.] 


"The  locomotion  or  displacement,  the  extension  or 
elongation,  and  the  partial  rupture  or  fraying  of  the 
peritoneum,  account  satisfactorily  for  the  origin  and 
increase  of  the  hernial  sac;  and  the  two  changes  first 
mentioned  explain  sufficiently  the  great  size  which  the 
bag  sometimes  attains.  Scrotal  ruptures  may  hang 
half  way  down  the  thigh  and  sometimes  nearly  reach 
the  knee;  yet  the  whole  inner  surface  of  the  swelling, 
in  which  all  the  loose  viscera  of  the  abdomen  may  be 
contained,  is  lined  by  a  continuation  of  the  peritoneum 
without  any  laceration  or  interruption."* 

M.  J.  Cloquet  also  made  many  experiments,  upon 
the  dead  body,  of  much  interest  and  value.  "  In  some 
individuals  the  natural  openings  of  the  abdominal 
parietes  are  large  and  loose;  if  we  push  the  finger 
through,  the  peritoneum  is  carried  before  it,  forming 
a  production  which  represents  a  hernial  sac.  Here 
the  cellular  tissue  is  not  torn,  but  elongated.  When 
the  pressure  is  discontinued,  the  membrane  gradually 
regains  its  original  position.  This  experiment  shows 
that  the  peritoneum  is  actually  displaced  in  the  forma- 
tion of  a  hernial  sac;  that  it  leaves  the  neighboring 
parts  to  pass  into  the  aponeuritic  opening.  The  ab- 
dominal parietes  lend  the  peritoneum  which  covers 
them  to  form  the  hernial  sac.  The  membrane  is 
hardly  stretched,  and  it  forms  folds  in  the  opening;  in 
some  instances,  it  is  both  displaced  and  elongated, 
covering  the  finger  closely. 


*A  Treatise  on  Ruptures,  by  W.  Lawrence,  p.  29,  1843. 


—  19  — 

In  other  subjects,  the  peritoneum  resists  more 
forcibly,  because  it  adheres  more  closely  to  the  parie- 
tes;  the  portion,  however,  near  to  the  tendinous  open- 
ing becomes  stretched;  its  laminae  separate  and  are 
partially  torn  and  may  thus  form  a  very  thin  sac,  dif- 
ferent from  that  in  the  former  instance,  which  has  the 
material  thickness  of  the  peritoneum.  The  displaced 
membrane,  in  this  case,  does  not  recover  its  former 
position,  and  we  find  partial  laceration  in  the  fundus 
of  the  sac."* 

The  peritoneal  sac  may  also  be  formed  by  causes 
acting  from  without.  It  is  a  common  occurrence,  a 
number  of  marked  instances  of  which  have  come 
under  my  personal  observation,  where  a  large  unsup- 
ported hydrocele  has,  by  its  dragging  weight,  caused 
the  depression  of  the  peritoneum  at  the  upper  orifice 
of  the  inguinal  canal  to  become  deepened  and  finally  a 
well-marked  hernia  ensued.  Cloquet  cites  an  interesting 
case  of  an  old  man  with  a  large  inguinal  hernia.  "  The 
sac  was  five  inches  long;  its  orifice  was  large  and  round- 
ed, and  its  cavity  was  divided  into  two  parts  by  a  fibrous 
prominent  ring.  Below  the  latter,  the  peritoneum 
was  thick,  whitish,  and  strongly  adherent  to  the  ex- 
ternal coverings;  above,  it  was  thin  and  transparent, 
as  in  the  abdomen.  The  descent  of  the  thickened 
ring  and  the  elongation  of  the  sac,  had  been  obviously 
caused  by  the  weight  of   a   large    hydrocele   of   the 


*Reserches  sur  les  Causes  I'Anat.  des  Hernies  Abdom. 


tunica  vaginalis,  which  adhered  firmly  to  the  lower 
part  of  the  hernial  tumor.  A  convolution  of  the  small 
intestine,  two  inches  and  a  half  long  and  unadherent, 
occupied  the  upper  division  of  the  sac,"* 

I  have  dwelt  at  greater  length  upon  the  peri- 
toneum and  its  relation  to  the  hernial  sac  than  is 
usually  found  in  works  on  hernia,  since  it  is  not  only 
interesting  and  important  in  the  consideration  of  the 
causation,  but,  more  especially,  when  we  shall  come 
later  to  emphasize  it  as  a  factor  to  be  taken  into  ac- 
count in  the  discussion  of  the  methods  for  the  cure  of 
hernia. 

Development  of  Inguinal  Canal. —  In  the  develop- 
mental processes  of  intra-uterine  life,  it  is  usually 
accepted  that  the  gubernaculum  testis,  contracting, 
carries  with  it  the  testicle,  the  portion  of  the  periton- 
eum which  is  to  form  the  tunica-vaginalis,  and  the 
lower  fibres  of  the  obliqus  internus  which  constitute 
the  cremaster. 

Between  the  fifth  and  sixth  month  of  intra-uterine 
life,  the  gubernaculum  testes  attains  its  development. 
It  completely  fills  the  inguinal  canal  and  lies  behind 
•the  peritoneum  anterior  to  the  psoas  muscle.  Accord- 
ing to  Mr.  Curling,  the  gubernaculum  divides  below 
into  three  processes;  the  external  and  broadest  is  con- 
nected with  Poupart's  ligament  in  the  inguinal  canal; 
the  middle  process  descends  along  the  inguinal  ring 
to  the  bottom  of  the  scrotum  where  it  joins  thedartos; 

*0p.  cit. 


21    

the  internal  one  is  firmly  attached  to  the  os  pubis  and 
sheath  of  the  rectus  muscle,  some  fibres  are  also  re- 
flected from  the  internal  oblique  on  to  the  front  of 
the  gubernaculum.  About  the  sixth  month,  the  testis 
descends  to  the  iliac  fossa  and  the  gubernaculum  is 
shortened.  During  the  seventh  month,  the  testis 
enters  the  internal  abdominal  ring,  carrying  before  it 
a  pouch  of  the  peritoneum,  the  processus  vaginalis. 
During  the  last  month  of  pregnancy,  the  testis  de- 
scends into  the  scrotum  and  the  lengthened  pouch  of 
peritoneum  is  still  open,  communicating  with  the 
peritoneal  cavity.  Usually,  at  birth,  the  upper  front  of 
this  popch  has  become  closed  and  the  obliteration  ex- 
tends gradually  downwards  to  within  a  short  distance 
of  the  testis.  This  remains  through  life  as  a  closed 
serous  sac,  the  tunica  vaginalis,  which  invests  the 
outer  surface  of  the  testis  and  epididymis  and  is  re- 
flected over  the  inner  surface  of  the  scrotum.  During 
the  descent  of  the  testis,  the  muscular  fibres  of  the 
gubernaculum  become  gradually  everted,  forming  a 
muscular  layer,  which  becomes  placed  external  to  the 
process  of  the  peritoneum,  surrounding  the  gland  and 
spermatic  cord,  and  constitutes  the  cremaster.  In  the 
female,  a  small  cord,  corresponding  to  the  gubernacu- 
lum in  the  male,  descends  to  the  inguinal  region  and, 
ultimately,  forms  the  round  ligament  of  the  uterus.  A 
pouch  of  peritoneum  accompanies  it,  along  the  in- 
guinal canal,  analagous  to  the  processus  vaginalis  in 
the  male  and  this  is  called  the  canal  of  Nuck. 


"  In  the  majority  of  new-born  infants,  some  por- 
tion of  the  vaginal  canal  still  remains.  In  twenty-one 
cases  Seller  found  four  in  which  it  was  open  on  both 
sides,  five  in  which  it  was  open  on  the  right  side,  and 
four  on  the  left.  In  fifty-three  new-born  infants. 
Camper  found  twenty-three  open  on  both  sides,  eleven 
on  the  right,  and  six  on  the  left.  Schreger  found  in 
thirteen  infants  that  the  canal  was  open  in  eight  on 
both  sides.  Paletta  gives  the  rule,  that  the  complete 
closure  of  the  vaginal  canal  takes  place  from  the 
twentieth  to  the  thirtieth  day  after  birth."*  When 
closure  does  not  take  place,  the  condition  known  as 
congenital  hydrocele  may  exist,  /.  e.  the  fluid  from  the 
peritoneal  cavity  gravitates  into  the  non-closed  tunica 
vaginalis,  which  becomes  distended  in  a  limited 
degree,  as  in  hydrocele.  The  fluid  gradually  returns 
when  in  a  recumbent  position.  This  condition  is  often 
complicated  with  hernia,  which,  in  this  instance,  fol- 
lows through  the  funicular  peritoneal  opening,  as  in 
congenital  hernia,  although  the  hernia  itself  may  not 
be  acquired  until  in  adult  life.  This  condition  is  rare, 
but  one  well  marked  case  has  come  under  my  notice 
where  this  condition  had  pertained  since  infancy  and 
the  canal  was  permanently  closed  under  the  irrita- 
tion caused  by  a  hard-pad  truss.  Sometime  later, 
after  a  bath,  in  pulling  himself,  hand-over-hand,  up 
into  the  port-hole  of  a  ship,  the  young  man    produced 


*A  Practical  Treatise  on  Hernia,  by  Joseph   H.  Warren 
Page  14. 


—  23  — 
a   hernia   which,  however,    was  easily  retained  by  a 
light  truss.     The  hydrocele  did  not  recur. 

Conge?iital  Hernia. — In  congenital  hernia,  the  sac 
is  formed  by  the  upper  portion  of  the  funicular  process 
of  the  peritoneum,  produced  by  the  descent  of  the  testis, 
remaining  unclosed.  In  the  arrested  development^ 
whatever  the  causes,  the  inguinal  rings  and  the  canal  are 
weak  and  the  depressed  peritoneal  pocket  becomes 
the  seat  of  increased  intra-peritoneal  pressure  and,  on 
this  account,  anatomically  considered,  congenital 
hernia  must  be  of  the  oblique  variety.  The  rings  in 
infantile  life,  however,  are  more  nearly  opposed  to 
each  other  than  after  development. 

When  the  canal,  formed  by  the  descent  of  the 
testis,  remains  unclosed,  the  serous  sheath  is  converted 
into  the  hernial  sac.  Haller  first  called  the  attention 
of  the  profession  to  this  condition  which  was  confirmed 
by  John  Hunter  and  Percival  Pott.  More  than  a 
century  ago,  the  latter  author  wrote,  "Ruptures  of 
this  kind  are  said  to  be  very  rare,  but  from  what  I 
have  observed,  both  in  the  living  and  the  dead,  I  am 
inclined  to  believe  that  they  happen  much  oftener  to 
adults  than  are  suspected."  While  Scarpa  observed 
"  that  it  is  impossible  to  turn  the  bottom  of  the  hernial 
sac  upwards  in  congenital  hernia,  as  may  be  done  in 
common  hernia,  leaving  the  spermatic  vessels  with  the 
testicles  in  their  situation;  for  it  is  not  possible  in  con- 
genital hernia,  to  raise  and  invert  the  bottom  of  the 
vaginal  coat,  forming  the  hernial   sac,  without  raising 


—  24  — 

and,  at  the  same  time,  turning  the  testicle  upwards  and 
the  spermatic  vessels  which  are  inserted  into  it.  Upon 
which  point  I  cannot  mention  but  with  horror,  the  in- 
jury which,  from  the  want  of  this  knowledge,  was 
practiced  upon  the  celebrated  physician,  Zimmerman, 
from  the  false  persuasion  under  which  the  surgeon 
labored,  of  being  able  to  raise  up  the  vaginal  coat, 
without  removing  the  spermatic  vessels  from  their 
situation,  and  to  tie  it  at  its  neck,  in  order  to  prevent 
the  return  of  the  hernia,  according  to  an  erroneous 
and  already  antiquated  notion.""^ 

Encysted  Hernia. — The  encysted  hernia  of  Sir 
Astley  Cooper,  sometimes  called  the  acquired  con- 
genital form,  or  the  infantile  hernia  of  Hey,  is  that 
where  the  ventral  orifice  of  the  sheath  is  occluded, 
but  the  canal  remains  open  continous  with  the  tunica 
vaginalis.  The  hernia  is  formed,  as  in  the  more  com- 
mon variety,  by  the  sac  consisting  of  the  parietal 
peritoneum,  but  it  is  forced,  with  its  contents,  into  the 
open  tunica  vaginalis. 

I  have  not  met  with  this  form  of  hernia  in  opera- 
lion,  and,  without  dissection,  it  might  not  be  diagnosti- 
•cated.  Sir  Astley  Cooper  reports  the  following  case, 
vwhich  he  had  the  opportunity  of  witnessing  under  the 
care  of  Mr.  Foster  at  Guy's  Hospital: 

"A  man  was  admitted  into  the  house  with  symp- 
toms of  strangulated  hernia,  which  the  usual  means 
failed    to    relieve   and   the    operation    proposed    and 


*Warren,  op.  cit. 


—  25  — 
urged,  but  the  patient  would  not  permit,  clioosing 
rather  to  die.  On  examining  his  body  after  death,  a 
sac  was  found  within  the  tunica  vaginaUs,  descendmg 
from  the  abdominal  ring  towards  the  testicle.  This 
sac  contained  a  portion  of  one  of  the  small  intestines, 
which  had  become  gangrenous.  The  stricture  was  at 
the  mouth  of  the  sac."  * 

In  the  normal  development,  the  serous  canal, 
through  which  the  testis  has  passed,  becomes  closed 
and  is  obliterated;  when  this  has  occurred  the  hernia 
can  no  longer  escape  by  this  tract,  and  the  sac  is  now 
formed  by  a  yielding  of  the  peritoneum  over  the  pro- 
truding parts.  This  is  by  far  the  more  common  con- 
dition. 

CHANGES    IN    THE    HERNIAL    SAC. 

In  the  protrusion  of  the  peritoneum  through  an 
opening  in  the  abdominal  parietes  it,  at  first,  passes 
unchanged  through  the  tendinous  ring,  which  is  more 
or  less  firm  and  resisting.  This  ring  supports  the 
mouth  of  the  sac  and  determines  its  form  and  size. 
Since  it  passes  generally  through  unyielding  tissues, 
the  neck  is  relatively  small,  while  the  body  of  the  sac^ 
comparatively  unrestricted,  is  usually  much  larger. 
The  direction,  or  axis  of  the  sac,  varies  in  its  course, 
dependent  upon  the  obliquity  of  its  openings.  The 
form  of  the  sac  is  necessarily  modified  by  the  opening 
through  which  it  escapes,  by  the  tissues  surrounding 

*  Cooper's  Lectures,  1839,  P^S^  340- 


—    26    — 

it,  and  the  resistance  which  is  made  to  its  progress. 
In  consequence,  the  shape  and  size  vary  greatly  as  in 
scrotal,  femoral,  or  umbilical  hernia. 

When  the  canal  remains  circular  and  tendinous, 
the  sac  has  an  elongated  and  a  somewhat  cylindrical 
shape.  This  is  generally  true  in  inguinal  hernia  when 
it  is  confined  to  the  sheath  of  the  spermatic  cord. 
Having  passed  below  this,  the  sac  expands  and  may 
become  globular  or  pyriform.  On  the  contrary,  when 
the  sac  has  escaped  through  a  direct  opening  in  the 
abdominal  parietes,  the  resistance  is  comparatively 
slight  and  equal  in  all  directions,  and  the  shape 
assumed  is  nearly  spherical  or  somewhat  flattened,  as 
in  umbilical  hernia. 

In  an  imperfectly  formed  inguinal  hernia  or 
bubonocele,  the  sac  will  be  irregular  and  flat,  often 
escaping  detection,  unless  the  examination  is  made 
with  care.  While  the  size  and  shape  of  the  hernial 
tumor  thus  varies  under  the  modifying  influences  of 
the  surrounding  tissues,  these,  in  turn,  are  changed 
under  the  pressure;  the  apertures  of  escape  being 
altered  in  size,  length,  and  direction.  "The  thickness 
of  the  neck  of  the  sac  varies  much.  In  small  ones  of 
a  conical  figure,  the  peritoneum  retains  its  natural 
structure  at  this  part,  simply  turning  over  and  lining 
the  aponeurotic  ring.  This  is  the  least  frequent  case; 
more  commonly,  in  passing  through  the  narrow  aper- 
ture, it  is  folded,  puckered,  contracted,  and-  gains  in 
thickness   what   it   loses  in    extent  of   surface.     The 


—    27    — 

whole  circumference  of  the  neck  presents  fine  folds, 
radiated  wrinkles,  more  or  less  numerous  and  ap- 
proximated to  each  other.  If  we  distend  these  folds 
they  are  seldom  completely  effaced,  as  the  two  mem- 
branous plates  which  form  each  of  them  become  ad- 
herent; this  puckering  or  gathering  of  the  peritoneum 
necessarily  increases  the  thickness  of  the  neck  of  the 
sac.  These  folds  are  the  rudiments  of  those  which 
form  when  the  mouth  of  the  sac  gradually  contracts. 
It  ultimately  disappears,  giving  origin  to  radiated 
marks,  disposed  like  the  rays  of  a  star  and  indicating 
the  place  of  its  former  existence.  ^  ^  ^  Some- 
times the  neck  of  the  sac  presents  a  rounded,  whitish, 
almost  fibrous,  and  very  firm  ring,  either  of  uniform  or 
varying  thickness,  in  different  points  of  its  circumfer- 
ence."* 

The  changes  which  the  neck  of  the  sac  under- 
goes are  often  very  important  in  the  considera- 
tion of  operative  measures  for  relief  or  cure.  It  is 
often  adherent  to  the  ring  through  which  it  escapes; 
rarely  it  is  attached  at  one  side  only;  the  peritoneal 
pouch  then  becomes  irregularly  saccated,  even  two 
distinct  pouches  may  form  and  descend  below  the 
ring,  having  a  common  opening  into  the  abdomen.  A 
sac,  under  the  pressure  of  a  truss,  may  be  kept  empty 
and  become  adherent  and  closed  at  its  neck,  and  thus 
a  cyst  be  formed.     A  closed  sac  developed  in  this  way 


M.  J.  Cloquet,  op.  cit. 


may  become  attached  to  a  more  recently  formed  hernia, 
and  be  itself  carried  down  with  the  advancing  tumor. 

These  conditions  are  fortunately  very  rare,  but  it 
should  be  kept  in  mind  that  they  do  occur,  otherwise, 
when  present  they  will  greatly  confuse  the  observer 
and  render  diagnosis  of  extreme  difficulty. 

The  so-called  spontaneous  reduction  and  the  cure 
of  hernia  under  the  pressure  of  a  well-fitting  pad,  are 
subjects  of  much  interest.  Although  M.  Cloquet  made 
his  observations  seventy  years  ago,  none  of  greater 
accuracy  or  value  can  be  quoted.  "  During  the  forma- 
tion and  growth  of  a  rupture,  the  peritoneum  passes, 
and  seems  in  a  manner  to  converge,  towards  the  open- 
ing through  which  the  parts  escape.  When  elongated, 
so  as  to  form  a  hernial  sac,  it  still  possesses  its  natural 
elasticity  and  contractibility,  which  coming  into  action 
when  the  distending  force  ceases  to  operate,  some- 
times produce  slowly  and  insensibly  this  spontaneous 
reduction  of  the  sac.  The  membrane,  in  such  cases, 
takes  a  retrograde  course;  the  portion  lining  the  abdo- 
minal parietes,  in  the  neighborhood  of  the  ring,  draws 
in  all  directions  on  the  neck  of  the  sac,  which  is  thus 
distended,  expanded,  and  at  last  effaced;  the  sac  is,  in 
a  manner,  unfolded  and  again  covers  the  parts  in  the 
neighborhood  of  the  aponeurotic  ring.  The  neck, 
which  is  the  part  last  formed,  is  the  first  to  disappear, 
while  the  restoration  of  the  fundus  is  the  last  step  in 
the  process,  and  is  accomplished  with  difficulty;  this 
kind  of  reduction  is  therefore  often  incomplete.  If 
the  neck  of  the  sac  is  a  fibrous  ring,  this  becomes  en- 


—    29    — 

larged,  expanded,  and  disappears  wholly  or  in  part. 
Previously  to  reduction,  it  was  applied  closely  to  the 
distended  ring,  and  of  course  possessed  the  same 
dimensions,  but  now  it  is  much  larger,  and  does  not 
correspond  to  the  part.  The  portion  of  membrane 
circumscribed  by  the  larger  circle,  which  it  now  forms, 
was  the  hernial  sac.  In  the  center  of  this  circle  I 
have  found,  in  two  instances,  a  depression  of  the  peri- 
toneum, formed  by  the  fundus  of  the  sac,  still  en- 
gaged in  the  aponeurotic  opening.  In  these  cases  the 
spontaneous  reduction  has  been  incomplete;  by  draw- 
ing downwards  the  portion  of  membrane  still  in  the 
ring,  the  enlarged  neck  was  gradually  brought  back  to 
the  aponeurotic  aperture  and  resumed  its  former 
dimensions.  *  *  *  Sometimes  the  sac  is  so  com- 
pletely effaced,  that  the  peritoneum  lining  the  ring 
shows  no  trace  of  its  existence.  The  only  proof  that 
there  has  been  a  hernia  is  a  whitish,  cellular,  empty 
cavity  arising  from  the  aponeurotic  ring;  this  cavity 
formerly  lodged  the  peritoneal  sac  and  is  ready  to 
receive  it,  if  it  should  be  formed  again.  This  mode 
of  reduction  must  be  tolerably  frequent,  in  recent 
herniae,  when  the  peritoneum  constituting  the  sac  has 
not  had  time  to  assume  a  texture  in  conformity  with 
its  new  position.  It  will  be  favored  by  the  pressure 
of  a  truss  on  the  ring,  or  by  the  patient  remaining 
constantly  in  a  recumbent  position.  This  reduction 
of  the  sac  will  be  much  more  difficult,  and  often  im- 
possible in  old  ruptures.     The  elasticity  and  contrac- 


—  30  — 

tility  of  the  peritoneum  lining  the  abdominal  parietes 
are  counterbalanced  and  surmounted  by  the  resistance 
of  the  fibrous  neck  of  the  sac,  by  the  disposition  fre- 
quently observed  in  that  neck  to  contract,  by  its  ad- 
hesion to  the  aponeurotic  opening,  and  the  firm  con- 
nection of  the  sac  to  the  neighboring  parts.  The 
weight  and  pressure  of  the  viscera,  when  they  con- 
tinue protruded,  act  together  with  the  causes  just 
enumerated,  in  opposition  to  the  contractility  of  the 
peritoneum  and  consequently  to  this  mode  of  reduc- 
tion."* The  hernial  sac  may  be  drawn  upwards  with- 
in the  abdominal  cavity,  by  the  distension  of  the 
bladder  from  retention  of  urine;  by  the  enlargement 
of  the  uterus  in  pregnancy;  by  the  formation  of  other 
herniae  in  close  proximity  to  the  first. 

The  pathological  changes  which  may  take  place 
in  the  sac  are  various;  direct  injuries,  wounds,  bruises, 
pressure  from  improperly  fitting  trusses,  any  violence 
may  cause  here  all  the  conditions  usually  ascribed  to 
inflammations  elsewhere.  Serous,  bloody,  and  turbid 
secretions  may  occur.  From  a  variety  of  causes,  the 
sac  may  become  infected  and  purulent  collections 
ensue.  The  sac  itself  becomes  thickened  and  changed 
so  as  to  lose  all  the  appearances  of  a  serous  mem- 
brane. I  have  recently  removed  the  sac  in  two  cases 
where  it  was  several  lines  thick.  One,  an  old  hernia, 
so   slight   as   to   give    little    trouble    until,   suddenly, 


*  M.  Cloquet,  Op.  cit. 


—  31  — 

strangulation  of  the  intestine  supervened  by  the 
escape  of  a  loop  through  the  ring.  The  second,  of 
oniy  three  months'  standing,  and  yet  the  hernia  was 
scrotal  and  the  omentum  adherent  to  the  much 
changed  walls  of  the  sac. 


CHAPTER  III. 

ANATOMY— DESCRIPTIVE  AND   SURGICAL 

The  cure  of  hernia  by  surgical  interference  is  the 
restoration  of  the  parts  involved,  as  nearly  as  possible, 
to  a  normal  condition.  To  do  this  intelligently,  pre- 
supposes a  thorough  knowledge  of  what  we  mean  to 
restore.  To  this  end,  the  anatomical  construction  of 
the  parts  involved  must  be  carefully  mastered.  For- 
tunately, there  is  little  need  of  original  work.  The 
great  teachers  of  former  generations  have  gone  over 
the  entire  field  with  such  pains-taking  care,  born  of 
enthusiastic  zeal,  that  little  can  be  gleaned  that  is 
new,  or  of  especial  value.  The  works  of  Camper,* 
Cooper,f  Scarpa,!  and  Cloquet  ||  will  ever  be  consid- 
ered as  monuments  of  industry  and  accuracy. 


*  Icones   Herniarum,   Peter   Camper,   1801,     The   plates 
were  engraved  in  1757. 

•f  Sir  Astley  P.  Cooper,  1804  and  1807. 

I  H.  Scarpa,  1812. 

I  J.  Cloquet,  1817  and  1819.  g 


§  The  latter  was  published  as  an  inaugural  thesis,  and  the  descrip- 
tions are  based  upon  the  examination  of  three  hundred  and  fifty  cases  of 
Jhernia  found  in  about  five  thousand  cadavers,  covering  a  period  of  three 
years  of  hospital  experience  in  Paris.  In  1819  he  published  "  Recherches 
sans  les  causes,  et  I'anatomi^  des  hernies  abdominalis,"  with  ten  plates. 
This  is  based  upon  five  hundred  post-mortem  examinations,  also  two 
hundred  anatomical  preparations  of  hernia  presented  to  the  Faculty  of 
Medicine  in  Paris. 


Many  others  have  also  furnished  contributions  of 
great  vaUie,  until  now  the  anatomy  of  hernia  leaves 
little  to  be  desired.  The  recent  work  of  Dr.  Joseph 
Warren,  of  Boston,  is  the  most  complete  and  satis- 
factory of  any  American  author.  The  present  chapter 
will  be  as  concise  as  the  importance  of  the  subject  will 
admit. 

IXGUIX.^L  HERNIA. 

The  construction  of  the  abdominal  walls  is  a 
beautiful  example  of  nature's  marvellous  adaptability 
of  means  to  the  end  to  be  subserved.  The  abdomen 
must  be  always  full,  no  matter  how  varied  its  contents, 
and  subject  to  equable  pressure.  The  amount  of 
pressure  varies  with  contents,  position  of  the  body, 
and  muscular  contractility  of  the  abdominal  walls. 
For  obvious  reason,  the  tension  is  greatest  at  the  low- 
est portion  of  any  supporting  cavity.  This  would  be 
the  pelvic  basin  but  for  the  disposition  of  the  bony 
structure  of  the  trunk,  where  the  relation  of  the  in- 
cline of  the  brim  of  the  pelvis  to  the  projection  of  the 
sacrum  throws  the  abdominal  weight  forward,  and 
lessens  materially  the  strain  upon  the  floor  of  the 
pelvis. 

The  firm  attachment  of  the  recti  to  the  ossa 
pubis  is  the  first  point  of  support,  and  this  rarely  fails 
in  man,  only  exceptionally  in  multiparous  women,  or 
after  long  distension  by  abdominal  tumors.  The 
power  and  tension  of  the  recti  muscles  are  well   illus- 


Superficial  dissection  of  inguinal  and  crural  regions.  Below  the  groove  upon 
front  of  thigh  is  seen  the  triangular  depression  forming  the  lower  part  of 
groin.  This  is  described  in  connection  with  Femoral  Hernia.  Above  the 
pubis  may  be  felt  the  opening,  in  the  deep  parts,  of  the  superficial  abdomhial 
ring  through  which  the  spermatic  cord  escapes  to  testicle.  Beneath  the 
skin  of  groin  and  fascia  superficialis  are  two  layers,  between  which  are 
found  the  superficial  vessels  and  lymphatics.  The  layer  below  this  is 
made  up  of  elastic  areolar  tissue  and  fat,  closely  attached  to  Poupart'a  liga- 
ment at  spine  of  pubis  and  crest  of  ilium,  g.  Crossing  the  groin  are  seen 
three  blood-vessels  turned  obliquely  inwards  and  upwards  from  common 
femoral  artery.  Outer  one,  superficial  circumflex  iliac,  passes  up  to  superior 
iliac  spine,  d.  The  middle  one,  superficial  epigastric,  supplying  glands  and 
integuments  of  groin  to  umbilicus,  e.  Inner  one,  /,  superficial  external 
pubic,  enters  fascia  lata  near  the  pubis,  crossing  beneath  spermatic  cord  to 
scrotum  and  root  of  penis.  The  external  pubic  is  liable  to  be  divided  in 
cure  of  Inguinal  Hernia  ;  if  a  dull  bistoury  be  used  in  making  the  division, 
haemorrhage  is  less  liable  to  occur,  unless  the  vessel  is  very  much  enlarged, 
which  is  tlie  case  sometimes  in  old  and  large  ruptures. 

The  abdominal  wall  is  made  up  of  layers  of  muscular  and  aponeurotic  tissue 
below  the  iliac  crests.  The  external  oblique  is  very  strong,  and  the  fibres 
curve  downwards  and  inwards  towards  median  line  and  pubis,  forming  with 
other  tendons  a  vertical  line  and  by  union  with  opposite  side  linea  alba. 


—  35  — 
trated  by  the  marked  resistance  to  pressure  seen  in 
laparotomy  in  subjects  where  the  recti  have  not  under- 
gone overstrain.  Even  when  the  patient  is  fully 
etherized,  they  are  so  unyielding  as  frequently  to  be  a 
cause  of  trouble  to  the  operator  in  reaching  the  bottom 
of  the  pelvis. 

In  hernia,  we  have  to  deal  with  the  rectus  simply 
as  a  point  of  support.  The  abdominal  fascia,  first 
described  by  Camper,  is  in  two  layers;  the  superficial 
is  thick  and  meshed,  containing  adipose  tissue;  the 
deep  layer  is  aponeurotic  and  firmly  adherent  to  the 
parts  beneath.  It  blends  with  and  goes  to  make  up 
the  linea  alba,  and  extends  below  to  Poupart's  liga- 
ment. There  are  only  three  pairs  of  muscles  which 
demand  our  attention:  the  external  oblique,  the  in- 
ternal oblique,  and  the  transversalis. 

The  external  oblique  arises  on  either  side  from 
the  eight  lower  ribs,  passes  towards  the  front  of  the 
abdomen,  and  joins  in  a  broad  tendon  anteriorly. 
This  union,  in  a  broad  aponeurosis,  extends  from  the 
ensiform  cartilage  to  the  pubis,  partly  on  the  side 
from  which  it  originates,  and  partly  on  the  opposite 
side;  it  is  also  inserted  into  the  spine  of  the  ilium. 

As  the  fibres  of  the  lower  and  thicker  part  pro- 
ceed obliquely  downwards  and  forwards,  they  separate 
about  an  inch  and  a  half  from  the  pubis  into  two  dis- 
tinct portions,  which  constitute  the  pillars  or  columns 
of  the  abdominal  ring.  The  upper  and  inner  of  these, 
which  is  broader  than  the  other,   is  attached   to  the 


-  36   - 

upper  edge  of  the  pubis,  near  the  symphysis;  some  of 
its  fibres  descend  and  decussate  with  those  of  the  op- 
posite side,  being  fixed  to  the  fibro-cartilage  which 
unites  the  two  bones.  The  lower  and  outer,  which  is 
narrower,  but,  at  the  same  time,  thicker  and  stronger 
than  the  other,  runs  obHquely  from  above  downwards, 
and  from  behind  forwards,  to  be  fixed  by  a  strong 
tendon  in  the  spine,  or  tubercle  and  crest  of  the  pubis. 
The  portion  of  the  aponeurosis,  which  extends 
between  the  anterior  spine  of  the  ihum  and  the  spine 
of  the  pubes,  is  a  broad  band,  folded  inwards  and  con- 
tinues below  with  the  fascia  lata:  Poupart's  ligament, 
sometimes  called  the  crural  arch.  The  portion  re- 
flected backwards  and  inwards  from  Poupart's  liga- 
ment to  the  pectineal  line  is  called  Gimbernat's  liga- 
ment. The  triangular  opening  formed  by  the  two 
tendinous  columns  at  their  insertion  is  known  as 
the  external  abdominal  ring.  Through  this  the  sper- 
matic cord  passes  in  the  male,  the  round  ligament 
in  the  female.  The  opening  is  directed  obliquely  up- 
wards and  outwards,  corresponding  with  the  same 
course  of  the  fibres  of  the  aponeurosis.  The  crest  of 
the  pubis  is  the  base  of  the  triangle,  the  two  pillars 
form  its  sides,  the  juncture  of  the  pillars  the  apex,  which 
is  strengthened  by  connecting  fibres,  curved  from 
above  downwards.  These  crossing,  interlacing  fibres 
are  sometimes  particularly  strong  in  old  herniae,  are 
better  developed  in  men  than  in  women,  and  are  occa- 
sionally wanting.     Although  this  opening  is  called  a 


Fig. 


Deej>  dissection  of  inguinal  canal  and  abdominal  wall,  a,  external  oblique  throvrn 
back  over  Poupart's  ligament  ;  6,  internal  obli([ue  ;  c,  transversalis  muscle  ; 
dy  conjoined  tendon  ;  c,  rectus  muscle  ;  /,  transver.salis  fascia  ;  (/,  triangular 
aponeurosis  formed  by  a  layer  of  tibrous  tissue  passing  across  linea  alba  from 
aponeurosis  of  external  oblique  of  opposite  side.  These  fibres  pass  outward 
and  downward  to  [»ubic  symphysis,  crest  and  spine,  or  even  to  pectineal  line, 
where  they  are  implanted  with  those  of  the  conjoined  tendon  ;  A,  muscular 
fibres  of  the  eremaster. 

The  fascia  transversalis,  uniting  at  the  groin  with  fibres  of  the  tendon  of  the 
transversalis  muscle,  is  closely  connected  with  Poupart's  ligament,  iliac  fa,scia 
and  conjoined  tendon.  Here  it  forms  the  oval  opening  of  the  internal  ab- 
dominal ring  and  gives  off  over  the  conl,  the  funnel-shaped  investment 
called  the  fascia  propria  or  infundibularis,  i. 


-  38  - 
ring,  it  is  never  one  unless  dilated  by  a  hernia.  In  its 
longest  diameter  it  measures  about  one  inch,  from  one 
tendon  to  the  other  only  about  half  an  inch.  The 
centre  of  the  opening  is  about  one  inch  and  a  quarter 
from  the  symphysis.  A  very  delicate  fascia  originates 
from  the  tendon  of  the  external  oblique  at  the  upper 
margin  of  the  ring,  passing  over  it  and  uniting  with 
the  spermatic  cord,  which  it  accompanies  in  its  de- 
scent into  the  scrotum  and  to  it  is  closely  adherent. 

The  internal  oblique  muscle  arises  from  the  outer 
half  of  Poupart's  ligament,  the  crest  of  the  ilium  and 
the  lumbar  fascia.  The  lower  edge  of  this  muscle 
passes  over  the  spermatic  cord  and  blends  with  the 
transversalis  to  form  the  conjoined  tendon  of  these 
muscles.  It  is  inserted  into  the  six  lower  ribs,  ensi- 
form  cartilage,  and  linea  alba.  The  conjoined  ten- 
don of  *the  internal  oblique  and  transversalis  is 
inserted  into  the  crest  of  the  os  pubis  and  pectineal 
line  immediately  behind  the  external  abdominal  ring, 
and  serves  to  protect  what  otherwise  would  be  a  weak 
point  in  the  abdominal  wall.  Sometimes  the  pressure 
from  within  is  so  great  upon  this  tendon,  that  it  fails 
as  a  support,  and  is  carried  in  front  of  the  hernial  sac, 
through  the  external  ring,  and  then  forms  one  of  the 
coverings  of  direct  inguinal  hernia. 

The  transversalis  muscle,  in  its  lower  portion, 
arises  from  the  outer  third  of  Poupart's  ligament  and 
the  crest  of  the  ilium,  and  is  inserted  into  the  linea 
alba.     The   lower   fibres   curve   downwards  and    are 


—  39  — 
inserted,  together  with  those  of  the  internal  oblique, 
into  the  crest  of  the  os  pubis  and  pectineal  line  form- 
ing the  conjoined  tendon  already  described.  The 
triangular  ligament  is  a  band  of  tendinous  fibres 
which  is  continued  from  Poupart's  ligament,  at  its 
attachment  to  the  pectineal  line  upwards  and  inwards, 
beneath  the  inner  pillar  of  the  external  ring,  to  the 
linea  alba.  The  transversalis  fascia  covers  the  space 
between  the  lower  border  of  this  muscle  and  Poupart's 
ligament.  This  fascia  lies  between  the  transversalis 
muscle  and  the  peritoneum.  It  is  a  part  of  the  fascia 
which  lines  the  interior  of  the  abdominal  and  pelvic 
cavities,  with  which  it  is  directly  continuous.  In  the 
inguinal  region,  this  fascia  is  thick  and  dense  and  is 
attached  externally  to  the  femoral  vessels  and  to  the 
posterior  margin  of  Poupart's  ligament.  It  also 
forms  the  anterior  wall  of  the  crural  sheath  of  the 
vessels  as  they  descend  into  the  thigh. 

The  internal  abdominal  ring  penetrates  the  trans- 
verse fascia,  midway  between  the  anterior  superior 
spine  of  the  ilium  and  the  spine  of  the  pubis,  and 
about  half  an  inch  above  Poupart's  ligament.  It  is 
oval  in  shape,  and  varies  in  size  in  different  individu- 
als, being  much  larger  in  the  male  than  in  the  female. 
It  is  limited  above,  by  the  arching  fibres  of  the  trans- 
versalis, and  internally,  by  the  epigastric  vessels. 
About  its  circumference,  a  thin,  funnel-shaped  mem- 
brane is  formed  from  the  transversalis  fascia  which 
is  continued  around  the  cord  and  testes  and  encloses 


Fig.  3. 


Dissection  from  the  peritoneal  surface  of  the  parts  affected  by  an  oblique  rupture  ; 
peritoneum,  its  fascia  and  the  trausversalis  fascia  are  removed.  The  sac  is  cut 
©ff  at  its  neck  in  the  deep  ring.  The  epigasti'ic  artery  is  seen  below  the  neck, 
but  has  been  icuiovi'd  at  the  inner  side  to  show  conjoined  tendon,  h. 


—  41  — 
them  in  a  distinct  sheath.  In  an  oblique  inguinal 
hernia  this  fascia  forms  one  of  the  coverings  of  the 
sac.  This  fascia  is  loosely  connected  to  the  peri- 
toneum and  in  fleshy  persons  often  a  layer  of  fat  is 
here  found. 

The  inguinal  canal  contains  the  spermatic  cord 
in  the  male,  and  the  round  ligament  in  the  female.  It 
is  about  an  inch  and  a  half  in  length  and  extends 
obliquely  downwards  and  inwards,  parallel  with,  and 
a  little  above  Poupart's  ligament.  Through  the  in- 
ternal abdominal  ring,  it  communicates  with  the  abdo- 
minal cavity  and  terminates  below  at  the  external  ring. 
In  its  entire  length,  it  is  limited,  in  front,  by  the 
aponeurosis  of  the  external  oblique,  in  the  outer  third, 
by  the  internal  oblique,  behind  by  the  conjoined 
tendon  of  the  internal  oblique  and  transversalis,  the 
triangular  ligament  and  the  transversalis  fascia,  below 
by  the  union  of  this  fascia  to  Poupart's  ligament. 
Oblique  inguinal  hernia  always  follows  the  line  of  this 
canal. 

"  The  finger  should  be  introduced  a  slight  dis- 
tance into  the  external  ring,  and  if  the  limb  is  e-x~, 
tended  and  rotated  outwards,  the  aponeurosis  of  t^ 
external  oblique,  together  with  the  iliac  portion  of  tiie 
fascia  lata  will  be  felt  to  become  tense,  and  the  ex- 
ternal ring  much  contracted;  if  the  limb  is,  on  the 
contrary,  flexed  upon  the  pelvis  and  rotated  inwards, 
this  aponeurosis  will  become  lax,  and  the  external 
ring  sufficiently  enlarged    to   admit   the    finger   with 


—  42   — 

comparative  ease;  hence  the  latter  position  should 
always  be  assumed  in  cases  where  taxis  is  applied  for 
the  reduction  of  an  inguinal  hernia,  in  order  that  the 
abdominal  walls  may  be  as  much  relaxed  as  possible."* 

SPERMATIC    VESSELS  AND  CORD. 

The  spermatic  vessels  placed  behind  the  peri- 
toneum, descend  from  the  loins,  over  the  surface  of  the 
psoas  and  iliacus  internus  muscles,  and  are  connected  to 
them  and  to  the  membrane  by  loose  cellular  substance; 
and  arrive  at  the  division  between  the  two  portions  of 
the  fascia  transversalis.  Here  they  are  joined  at  an 
angle  more  or  less  acute,  by  the  vas  deferens,  and  the 
spermatic  cord,  which  results  from  this  junction, 
making  a  sudden  bend  inwards,  passes  into  the 
inguinal  canal  through  its  upper  or  inner  aper- 
ture. The  vas  deferens  is  placed  in  the  canal  behind 
and  towards  the  inner  side  of  the  vessels,  and  conse- 
quently under  the  fleshy  margin  of  the  obliquus  inter- 
nus and  transversus,  the  exact  situation  of  its  passage 
being  marked  by  a  slight  depression  of  the  peri- 
toneum. The  cord  thus  goes  obliquely  downwards 
and  inwards,  between  the  fascia  transversalis  and  the 
aponeurosis  of  the  external  oblique,  being  increased 
in  size  by  the  addition  of  the  muscular  fibres,  called 
the  cremaster  muscle,  derived  from  the  lower  edge  of 
the  internal  oblique  and  from  the  crural  arch.      The 


Gray's  Anatomy,  p.  694. 


—  43  — 
cord  finally  emerges  through  the  opening  in  the  ten- 
don of  the  obliquus  externus,  and  then  turns  suddenly 
downwards;  lying  not  so  much  on  the  bone  between 
the  two  columns  of  the  rings,  as  on  the  outer  column 
itself,  so  as  to  cover  the  insertion  into  the  pubes. 

Thus  the  vessels  of  the  testicle,  making  two  re- 
markable turns,  pursue  three  different  directions  in 
the  successive  parts  of  their  course. 

They  descend,  inclining  at  the  same  time  a  little 
outward,  from  the  loins  to  the  opening  in  the  fascia 
transversalis.  Then  they  bend  inwards  and  forwards 
between  that  fascia  and  the  aponeurosis  of  the  exter- 
nal oblique,  making  a  curve,  of  which  the  concavity  is 
turned  towards  the  pubes;  the  vas  deferens  makes  a 
sharp  angular  t\irn  at  that  part.  The  spermatic  cord 
makes  a  second  turn,  with  its  convexity  towards  the 
pubes,  and  lastly,  descends  straight  to  the  testicle."* 
The  cord,  besides  the  vas  deferens,  is  made  up  of 
arteries,  "  veins,  nerves,  lymphatics,  a  membranous 
sheath,  and  the  cremaster  muscle.  The  spermatic 
artery  is  given  off  from  the  aorta  a  little  below  the 
superior  mesenteric  branches.  Opposite  the  middle 
of  Poupart's  ligament,  it  passes  from  the  lower  part  of 
the  abdomen  and  joins  the  cord  running  to  the  tes- 
ticle. 

The  spermatic  vein,  arising  from  the  testis,   re- 
turns along  the  cord   to   the   abdomen.     Two    small 


*  Lawrence  on  Ruptures,  p.  i6o. 


Fig.   4. 

Dissection  of  Inguinal  and  Crural  Hernia  from  internal  surface,  the  peritoneum 
:i;il  fascia  being  removed,  a,  external  iliac  artery;  b,  epigastric  artery, 
luinch  of  a  ;  d,  deep  circumflex  iliac,  lying  in  He.sselbach's  triangle  ;  e,  rec- 
tus muscle  ;  /,  fascia  transversal  is  ;  g,  vas  deferens  or  spermatic  duct  ; 
h,  spermatic  plexus  of  veins  with  artery  and  nerves  ;  i,  obliterated  cord  of 
hypogastric  artery  ;  /•,  lymphatic  glasds.  At  the  internal  ring  may  b?  Soeii 
subperitoneal  fascia,  /,  enveloping  the  cord,  h. 


—  45  — 
arterial  branches  are  also  generally  a  part  of  the  cord, 
one  from  the  internal  iliac  accompanies  the  vas  defer- 
ens, the  other  a  branch  of  the  epigastric.  An  accurate 
knowledge  of  the  course  of  the  epigastric  artery  is 
essential  in  operations  for  hernia,  since  it  is  situated 
so  near  the  spermatic  cord.  This  vessel  arises  from 
the  iliac  artery,  behind  Poupart's  ligament  and  passes 
upwards  and  inwards  close  to  the  under  and  inner 
side  of  the  cord,  between  it  and  the  symphysis.-  Here 
it  gives  off  a  branch  to  the  cord.  For  nearly  two 
inches  of  its  course  it  lies  posterior  to  all  the  ab- 
dominal muscles,  beneath  the  peritoneum.  It  ascends 
obliquely  and  upwards  to  the  margin  of  the  sheath  of 
the  rectus  muscle.  In  its  course,  it  lies  behind  the  in- 
guinal canal,  to  the  inner  side  of  the  internal  ab- 
dominal ring  and  immediately  above  the  femoral  ring. 
The  epigastric  varies  considerably  in  its  origin  and 
branches.  The  position  of  the  artery,  concerned  in 
hernia,  is  the  beginning  of  its  course,  close  to  the 
inner  and  under  side  of  the  spermatic  cord  where  the 
latter  issues  from  the  internal  ring.  Here  the  artery 
is -generally  three  inches  from  the  symphysis  pubis, 
and  is  the  same  distance  from  the  spine  of  the  ilium. 

The  artery  is  accompanied  by  veins  of  which  the 
largest  is  constantly  found  on  the  inner  side  of  the 
artery.  They  end  by  a  single  trunk  in  the  iliac 
vein. 

As  will  be  seen  from  the  foregoing  description, 
the  inguinal  canal  is  not  an  open,  but  a  closed  passage 


-  46  — 

through  the  abdominal  walls;  a  passage  for  the 
transmission  of  important  vessels,  but  so  fortified  by 
fascia,  muscle,  and  tendon,  as  to  hold  its  walls  normal- 
ly in  close  apposition,  bringing  intra-abdominal  pres- 
sure to  bear,  not  in  line  with  its  opening,  but  at  a  wide 
angle  to  it.  Pressure  thus  disposed  can  never  make 
an  oblique  inguinal  hernia,  but  the  rather  will  close 
the  canal.  A  beautiful  illustration  of  this  is  seen  in 
the  passage  of  the  ureter,  obliquely  through  the 
bladder  wall. 

"  A  simple  contrivance  gives  a  very  clear  idea  of 
the  manner  in  which  the  inguinal  canal  is  formed. 
Let  one  take  two  slips  of  paper  and  cut  two  small 
holes  in  the  centre  of  each.  Let  him  then  lay  these 
holes  opposite  each  other,  and  pass  through  them  a 
quill  or  pencil  case.  When  he  has  done  this  he  has  a 
very  good  plan  of  the  state  of  the  parts  about  the 
groin  in  the  foetus.  If  he  now  holds  the  papers 
opposite  him  and  then  pulls  to  one  side  the  one  near- 
est to  him,  he  will  find  by  so  doing  he  comes  to  lay 
the  quill  between  the  pieces  of  paper  in  the  same  way 
that  the  spermatic  cord,  by  the  extension  upwards 
and  outwards  of  the  internal  orifice  of  the  ring,  comes 
to  be  lodged  in  the  canal.  He  will  also  see  that  the 
length  of  the  canal  must  vary  according  to  the  greater 
or  less  extension  of  its  posterior  side.  On  pages  56 
and  69  of  the  present  work,  it  will  be  seen  that  the 
author  has  expressly  stated  that  the  inguinal  and 
femoral    canals    are  not  properly  canals    unless  dis- 


Fig.  5. 

Inguinal  Hernia,  Showing  the  Internal  Oblique  and  Cremaster 
Muscles,  and  Spermatic  Cord.— Gray. 


-  48  - 

tended   by   a   hernia.       In  a  normal   state  they  are 
simply  flattened  passages."* 

As  described  by  Dr.  Darling,  the  inguinal  canal 
has  the  following  boundaries: 


Structures  in  front 


Structures  behind 


Structures   above 


Structures  below 


rSkin. 

J  Superficial  fascia  (2  layers). 
1  External  oblique  (entire  length), 
[internal  oblique  (outer  third). 

'  Conjoined    tendon  of   internal  oblique 

and  transversalis. 
Transversalis  fascia. 
j  Triangular  ligament. 
}  Sub-peritoneal  tissue  and  fat. 
[  Peritoneum. 

Fibres  of  internal  oblique. 
Fibres  of  transversalis. 

(  Poupart's  ligament. 
1  Transversalis  fascia.  , 


OBLIQUE  INGUINAL  HERNIA, 

From  the  anatomical  description  already  given 
of  the  inguinal  canal,  we  can  readily  see  that  a  modi- 
ficatioii  of  the  intra-abdominal  pressure,  diverting  it 
in  the  line  of  the  opening,  is  necessary  at  its  very  in- 
ception. We  dwelt  in  detail  upon  the  various  changes 
which  take  place  in  the  peritoneum  in  the  formation 
of  the  sac.  It  is  now  much  more  generally  accepted 
than  formerly  by  anatomists  and  surgeons,  that,  in  a 


*  Joseph  Warren,  Hernia,  Sec.  Ed.  Page  6. 


—  49  — 
very  large  proportion  of  cases  of  inguinal  hernia, 
taking  the  direction  of  the  cord,  its  predisposing 
factor  is  found  in  the  defect  of  the  imperfect  closure 
of  the  peritoneal  pouch  which  descends  before  the 
testis. 

In  classification,  this  variety  has  been  sometimes 
called  congenital  hernia,  a  term,  as  generally  used,  suf- 
ficiently accurate.  The  irregular  depression  in  the 
peritoneum  thus  left  at  the  internal  ring,  affords  a 
slight  obstruction  to  the  free  movements  of  the  ab- 
dominal organs.  Thus,  little  by  little,  the  thin,  yield- 
ing peritoneum  is  saccated  and  a  wedge-shaped  pres- 
sure, at  first  slight  and  interrupted,  is  formed  in  the 
line  of  the  canal. 

This  pathological  factorage  having  been  estab- 
lished, it  is  easy  to  understand  that  a  comparatively 
slight  force  is  ample  to  separate  the  structures  which 
make  up  the  canal.  The  thin  margin  of  the  con- 
joined tendon  yields,  and  then  the  force  is  brought  to 
bear  upon  the  external  ring  of  the  canal,  protected 
posteriorly  only  by  the  aponeurosis  of  the  fascia 
transversalis  and  the  triangular  ligament.  Externally, 
the  upper  border  of  the  canal,  protected  by  its  re- 
enforcing  fibres  which  give  great  support  to  resist 
forces  acting  from  without,  is  yet  imperfectly  con- 
structed to  restrain  an  impinging  force  acting  from 
above  downwards. 

When  the  contents  of  a  hernial  tumor  have  thus 
distended  and   distorted   the  inguinal   canal,   the  im- 


/i--., 


Fig.  6. 

Inguinal  Hernia,  Showing  the  Transversalis  Muscle,  the 
Transversalis  Fascia,  and  the  Internal  Abdominal  Ring. — 
Gray. 


—  51  — 
portant  barrier  to  its  further  progress  is  overcome. 
The  peritoneal  sac  protrudes  over  the  spermatic  ves- 
sels and  separates  them  from  the  delicate  fibres  of  the 
cremaster  and  superficial  fascia.  The  contents  of  the 
tumor,  unrestrained,  oftentimes  almost  by  gravity, 
find  their  way  into  the  scrotum.  For  convenient 
differentiation,  the  tumor  thus  situated  is  called 
scrotal  hernia.  Not  rarely,  the  tumor,  formed  in  this 
way,  becomes  of  very  considerable  size,  sometimes 
enormous.  ''One  of  the  largest  of  these  swellings 
which  I  have  ever  seen  was  in  a  man  who  was  sent  to 
me  at  Guy's  Hospital  by  Mr.  White,  surgeon  at 
Lambeth.  It  reached  to  the  patient's  knees;  its  length 
was  then  twenty-two  inches,  and  its  circumference 
thirty-two."* 

When  inguinal  hernia  has  existed  for  a  consider- 
able time,  unrestrained,  the  constant  pressure  dilates 
the  parts  in  all  directions.  The  opening,  through 
which  it  passes  out  from  the  abdomen,  yields  more 
readily  toward  the  median  line,  until,  at  length,  in  old 
and  large  herniae,  the  opening  of  the  sac  is  in  close 
approximation  to  and  nearly  opposite  the  external 
ring. 

When  the  tumor  is  intestinal,  it  is  elastic  and 
uniform  in  feel,  and  when  returned  into  the  abdomen 
generally  produces  a  gurgling  sound. 

When  its  contents  consist  of  omentum,  it  is  usu- 


*Sir  Astley  Cooper,  Op.  cit. 


—  52  — 
ally  irregular  in  shape,  gives  an  indefinite  doughy  or 
inelastic  feel  and,  if  pushed  up  through  the  canal, 
emits  no  sound.  Usually  the  inguinal  hernial  tumor 
is  composed  of  both  omentum  and  intestine — entero- 
epiplocele.  The  differentiation,  however,  is  generally 
not  difficult. 

This  form  of  hernia  is  by  far  the  most  frequent, 
occurring  more  often  than  all  the  other  varieties  com- 
bined, and  is  found  oftener  upon  the  right  than  the 
left  side. 

Hernia  is  usually  easily  diagnosticated.  Hydro- 
cele, hematocele,  varicocele,  cysts  upon  the  cord,  en- 
larged testicle  are  all  to  be  considered  as  possibly 
confusing  or  complicating  the  diagnosis. 

REDUCIBLE    INGUINAL    HERNIA. 

Under  this  division  may  be  included  by  far  the 
larger  number  of  the  ruptured;  the  great  army  of 
semi-disabled,  truss-bearing  individuals  of  every  gen- 
eration and  race.  The  protrusion,  more  or  less 
marked,  gives  a  sense  of  weakness  and  discomfort 
never  absent,  but  varying  greatly  in  degree.  In  the 
recumbent  position,  pressure  upon  the  protruding 
parts  causes  them  to  be  returned  into  the  cavity  of 
the  abdomen.  In  the  larger  proportion  of  cases,  a 
properly  fitting  truss  retains  the  hernia. 

Often,  however,  after  unusual  exertion,  the  tumor 
becomes  large  and  its  reduction  is  attended  with  diffi- 
culty.    The  individual,  with   such    infirmity,  lives   in 


—  S3  — 
constant  danger.  Accidents  in  great  variety,  often 
from  the  most  trivial  cause,  may  produce  a  strangula- 
tion of  the  prolapsed  intestine,  the  consequences  of 
which  will  be  fatal,  unless  early  relieved  by  skillful 
attention.  To  prevent  this,  as  far  as  possible,  and 
make  comfortable,  rather  than  to  produce  a  cure,  the 
truss  has  been  devised. 


CHAPTER  IV. 

INSTRUMENTAL  SUPPORTS. 

It  is  not  my  purpose  in  this  treatise  to  enter  into 
a  detailed  description  of,  or  especially  to  differentiate 
between  instruments  of  support.  Although  the  variety 
of  trusses  seems  almost  infinite,  when  the  stock  of  a 
large  dealer  is  examined,  certainly  confusing  to  the 
young  or  inexperienced,  new  patterns  being  con- 
stantly offered  as  possessing  some  hitherto  unknown 
merit,  little  real  advance  in  the  art  of  truss  making 
has  taken  place  since  the  days  of  Sir  Astley  Cooper, 
nearly  a  century  ago.  After  discarding  the  use  of  all 
other  supports  and  bandages,  as  of  no  value,  often  of 
damage,  he  describes  a  truss  as  follows: 

*'  A  steel  truss  is  composed  of  a  pad  made  of  a 
supporting  piece  of  iron,  and  stuffed  so  as  to  take  a 
conical  form,  the  apex  of  which  immediately  com- 
presses the  abdomen  at  the  part  whence  the  hernia 
threatens  to  descend.  The  pad  is  riveted  upon  a 
long  flat  piece,  tempered  to  a  great  degree  of  elas- 
ticity, and  curved  to  the  shape  of  the  lower  part  of 
the  body,  which  it  embraces,  like  a  belt.  The  length 
of  this  steel  should  be  sufficient  to  pass  from  the 
hernia  round  the  region  of  the  groin  to  about  an  inch 
beyond  the  spine  behind,  forming  somewhat  more 
than  a  semi-circle,  but  compressed.  Both  the  pad 
and  truss  are  quilted  with  leather.     A  strap  of  leather 


—  55  — 
proceeds  from  the  hind  end  of  the  truss,  which  passes 
round  the  body,  completing  the  circular  belt  by 
fastening  upon  the  pad.  *  *  *  Many  surgeons, 
and  almost  every  surgeon's  instrument  maker,  have 
thought  proper  to  vary  the  form  of  the  truss,  and  to 
prescribe  different  rules  for  the  duration  and  force  of 
the  pressure,  but  almost  all  have  agreed  in  determin- 
ing that  the  pressure  should  be  made  upon  the  abdo- 
minal ring. 

This  is  precisely  the  circumstance,  however,  in 
which  they  are  all  defective;  and,  indeed,  it  is  the  fre- 
quent failure  of  the  purpose  for  which  they  are 
designed,  when  made  according  to  this  principle,  that 
has  led  to  such  a  variety  in  the  mode  of  their  con- 
struction. The  object  in  applying  a  truss  is  to  close 
the  mouth  of  the  hernial  sac,  and  destroy  its  communi- 
cation with  the  abdomen;  and  this  object  can  never  be 
perfectly  fulfilled  by  any  truss  which  is  applied  in  the 
usual  manner  upon  the  abdominal  ring,  and  extend- 
ing from  it  upon  the  os  pubis.  In  this  case  the  cure 
must  be  incomplete,  because  a  considerable  portion  of 
the  hernial  sac  remains  uncompressed  towards  the 
abdomen,  which  portion  is  that  situated  between  the 
abdominal  ring  and  the  opening  of  the  sac  into  the 
cavity  of  the  belly."* 

Even  when  the  truss  has  been  worn,  appar- 
ently    successfully,    for     some    time,   over    the    ex.- 


Sir  A.  Cooper,  p.  14. 


-  56  - 

ternal  ring,  should  this  become  closed  under  the 
pressure,  the  neck  of  the  sac  is  left  open  to  re- 
ceive the  wedge-like  dilating  force  of  the  abdominal 
organs,  and  the  supposed  cure  soon  fails.  Not 
seldom,  the  pressure  is  directed  so  low  as  to  in- 
jure the  cord,  interfere  with  the  nutrition  of  the  testis 
by  disturbed  or  impeded  circulation,  and  cause  severe 
suffering.  If  cure  is  to  be  effected  by  a  truss,  it  must 
bring,  and  continue  to  hold  the  sides  of  the  mouth  of 
the  sac  together,  so  as  to  prevent  its  being  opened  by 
the  insinuation  of  the  viscera,  and  in  time  cause  ad- 
hesion, and  obliteration  of  the  sac. 

Such  cases  occur,  but  are  the  decided  exception 
and  are  usually  in  the  young. 

The  surgeon  should  not  only  practically  under- 
stand the  proper  method  of  fitting  a  truss,  but  should 
consider  it  a  personal  duty  to  see  that,  the  instrument 
is  rightly  applied,  of  suitable  strength,  a  well-fitting 
pad,  and  should  give  the  sufferer  the  requisite  details  of 
instruction  as  to  its  wearing.  It  is  also  well  to  imform 
the  patient  that  it  will  require  time  to  render  the  sup- 
port fairly  bearable.  The  skin,  under  the  pad,  will 
need  attention  for  some  time,  as  friction  and  soreness 
ensue.  Often  a  fold  of  India  silk,  as  for  example, 
an  old  handkerchief  is  of  the  greatest  comfort.  Indi- 
viduals, after  the  middle  life,  may  not  expect  a  cure 
and  should  be  taught  to  look  upon  a  truss  as  a  part  of 
the  impedimenta  of  subsequent  living. 

We  cannot  do  better  than  emphasize  the  direction 


—  57  — 
of  Sir  Astley  Cooper,  to  make  the  pressure  over  the 
internal  ring,  and,  as  a  rule,  not  with  a  large  pad.  A 
small  well-fitting  pad  which  the  proper  adjustment  of 
the  truss  will  allow  to  be  retained  over  the  exit  from  the 
abdomen  is  the  end  to  be  attained.  While  the  curve 
of  the  spring  should  be  adjusted  to  the  configuration 
of  the  wearer,  as  far  as  practicable,  it  should  lie  above 
the  region  of  the  glutei  muscles;  otherwise,  their  ac- 
tion in  locomotion  produces  a  constant  motion  of  the 
pad. 

Trusses  may  be  divided  into  two  general  classes: 
the  French,  and  German  or  English.  The  former  has 
a  very  light,  but  highly  elastic  spring,  clinging  closely 
to  the  body  and  following  up  the  retreating  parts  in 
every  motion.  By  it,  constant  pressure  is  preserved. 
On  the  contrary,  the  German  form  is  a  much  heavier 
spring,  shaped  so  as  to  conform  to  the  outline  of  the 
body,  is  by  so  much  inelastic  and  less  comfortable. 
It  resists,  on  this  account,  with  great  power  any  strain 
brought  to  bear  upon  the  parts  in  contraction,  but 
presses  only  lightly,  or  not  at  all,  when  the  body  is  at 
rest.  American  ingenuity  has  found  a  fertile  field  in 
truss  making,  which  of  itself  would  make  a  chapter  of 
interest.  The  small  hard  pad  of  wood,  or  ivory,  with 
a  spring  constructed  so  as  to  carry  the  supporting 
force  obliquely  upwards  in  the  direction  of  the  canal 
(the  White  truss),  often  serves  a  valuable  purpose. 
This  is  a  modification  of  the  wood  pad  first  devised 
and   sold,  about  1835,  as   the    Stagner   truss.     These 


-  58- 

were  greatly  improved  by  Dr.  Chase*  and  others.  The 
water  pad,  invented  by  Dr.  Nathaniel  Greene,  of 
Boston,  rubber  filled  with  water,  is  also  a  valuable 
contribution  to  both  comfort  and  convenience.  Where 
a  light  pressure  only  is  required,  it  is  often  of  the 
highest  value.  Since  we  shall  not  again  return 
to  the  subject  of  supports,  it  may  be  added  that 
the  femoral  hernia  requires  an  instrument  adapted  to 
make  the  support  quite  lower  than  in  inguinal  hernia. 
In  large  irreducible  hernia,  special  supporting  and  con- 
stricting bags,  lacing  or  otherwise,  have  been  devised, 
and,  when  for  any  reason  operative  measures  are  not 
advised,  should  always  be  carefully  applied.  Um- 
bilical trusses  are  made  also  in  considerable  variety, 
but  in  all,  the  one  general  object  is  to  obtain  a  sup- 
port, to  prevent  the  escape  of  the  hernia  or,  where  this 
is  impossible,  to  retain  from  greater  enlargment. 


*Treaiise  on  the  Radical  Cure  of  Hernia  by  Instruments, 
by  Heber  Chase.  M.  D.,  Phil.  1836. 


CHAPTER  V. 

IRREDUCIBLE  AND  STRANGULATED  HERNIA. 

IRREDUCIBLE    HERNIA. 

Quite  a  variety  of  causes  produce  this  condition. 
Usually  the  history  is  given  of  a  hernia  which  has  ex- 
isted for  years,  often  not  supported  even  by  a  truss, 
or  one  that  fitted  improperly  and  had  been  discarded. 
More  commonly,  the  omentum  is  the  first  troublesome 
factor,  adhesions  between  it  and  the  walls  of  the  sac, 
and  this  again  to  the  contiguous  parts  prevent  return; 
as  the  opening  shortens  and  enlarges,  a  loop  of  intes- 
tine becomes  a  factor,  and  gaseous  or  faecal  distension 
causes  a  further  yielding  of  the  weakened  parts;  often 
symptoms  of  obstruction,  pain,  constitutional  disturb- 
ance, slight  elevation  of  temperature,  nausea,  followed 
by  vomiting,  are  the  premonitory  symptoms  of  danger 
which  precede  actual  strangulation.     Not  seldom,  al- 
though the  tumor  cannot  be  reduced,  a  careful  mani- 
pulation may  remove  the  temporary  obstruction,  the 
gaseous   distension   be  overcome,   and  the  intestinal 
canal  resume   its   function.     The   general    history  of 
such  cases  is  that  of  invalidism,  steadily  growing  more 
pronounced.     Often   rest  in  the  recumbent   position 
for  some  days,  the  hips  higher  than  the  shoulders,  and 
the    parts   supported,    hot   applications   locally,  light 
diet,  opiates,  enemata,   etc.,  are  demanded.     In  this 


—  6o  — 

way  relief  is  obtained  without  manipulation  or  taxis, 
and  when  these  measures  are  resorted  to  they  should 
be  conducted  with  the  greatest  care.  The  size  of  the 
irreducible  hernia  is  sometimes  enormous.  Often 
when  the  patient  is  about,  the  scrotal  tumor  becomes 
a  deformity  difficult  to  conceal.  Birkett  reports  the 
following:  "  The  largest  double  rupture  I  have  seen 
was  in  a  bricklayer,  fifty-five  years  old,  whose  bodily 
health,  strength,  and  conformation  were  in  other  re- 
spects good.  The  left  hernial  tumor  was  the  largest, 
although  it  had  only  existed  about  three  years,  whilst 
the  right  had  been  there  twelve  years.  The  lowest 
body  of  the  tumor  very  nearly  reached  to  a  level  with 
the  patellae.  Its  circumference  in  its  largest  part 
measured  thirty  inches,"* 

Besides  the  inconvenience  of  such  tumors  and 
their  attendant  suffering,  the  patient  runs  many 
dangers.  The  greatest  is  strangulation  of  the  incar- 
cerated intestine,  although  this  is  probably  less  than 
in  reducible  hernia,  since  the  sac  is  nearly  full  and  the 
less  readily  admits  of  a  sudden  increase  of  contents. 
Injuries  are  common  from  accidents. 

Cooper  relates  a  case  where  death  occurred  in 
a  few  hours,  after  a  fall,  from  rupture  of  a  portion  of 
the  ilium.  He  also  quotes  a  case  from  Mr.  Norris,  a 
contemporary  surgeon,  who  showed  him  the  speci- 
men. 


*  Holmes'  System  of  Surgery. 


—  6i   — 

"Whilst  running,  and  suddenly  turning  the  corner 
of  a  street,  he    struck    violently  against  a  post.     The 
middle  of  the  abdomen  was  the  part  that  received  the 
shock,f rom  the  effects  of  which  he  soon  appeared  to  have 
recovered,  but  on  proceeding  a  little  way  he  felt  great 
pain    in    the    belly,    and   became   very   faint,    which 
obliged  him  to  sit  down  on  the  steps  of  a  door.     In 
about  ten  minutes  he  was  just  enough  recovered  to  be 
able   to   crawl   to   his   home,   which   was   about   two 
hundred  yards  off.     I  saw  him  on  the  following  morn- 
ing.    There  was  not  the  slightest  appearance  of  injury 
on  the  part  that  had   received  the  stroke,  but  on  the 
course   of  the  spermatic  process  on  the  left  side  ex- 
tending into  the  abdomen,  there  was  a  fullness  and 
enlargement  equal  to  a  moderate  sized  hernia.     He 
vomited  quite  frequently,  his  pulse  was  quick  and  ex- 
tremely feeble,  his  countenance  was  pale  and  express- 
ive of  the    greatest    anxiety,  and  he  complained   of 
acute  pain  all  over  his  belly.     The  abdomen,  however, 
was  quite  soft,  and  the  contents  of  the  tumor  were 
easily  returned  into  its  cavity,  but  quickly  came  down 
again  when  the  pressure  was  removed.     These  symp- 
toms continued  with  the  most  torturing  pain  till  the 
evening,  when  he  expired.     Having  obtained  leave  to 
open  the   body,  Dr.  Telloly  and  myself  met  the  day 
after  his  death  for  that  purpose.     The  tumor  was  now 
larger  than  before,  discolored,  and  contained  air,  dis- 
coverable to  the  touch.     The  contents  of  the  tumor 
were  found,  on  opening  it,  to  be  air,  blood,  and  water. 


—    62    — 

On  examining  tlie  abdomen  a  similar  fluid,  to  the 
quantity  of  a  quart,  was  found  effused.  An  irregular 
aperture  was  perceived  in  the  ilium,  which  readily 
admitted  my  finger,  and  through  which  everything 
that  had  descended  into  the  stomach  found  a  ready 
passage  into  the  cavity  of  the  belly.  No  other  injury 
of  any  kind  to  any  of  the  contents  of  the  abdomen 
could  be  detected."  * 

Foreign  bodies  introduced  into  the  stomach  may 
be  caught  and  retained  in  the  intestinal  hernial  loop 
and  serious  trouble  arise  therefrom.  Cooper  relates  a 
case  of  a  boy  aged  thirteen  sent  to  hospital  where  a 
quantity  of  foeculent  matter  was  constantly  passing 
from  an  irreducible  scrotal  hernia.  Five  weeks  be- 
fore, he  had  accidentally  swallowed  a  pin.  This  was 
withdrawn  from  the  scrotal  opening,  but  after  a  variety 
of  efforts  to  cure,  he  was  discharged  with  the  fistula 
still  open.  The  case  of  Mr.  Gibbon,  the  celebrated 
historian,  is  given  by  Sir  Astley  Cooper  as  an  illustra- 
tion of  possible  danger.  Its  interest  is  quite  suffi- 
cient for  giving  entire. 

"  Mr.  Gibbon  had  been  for  thirty  years  subject  to 
a  scrotal  hernia  on  the  left  side,  of  which  he  made  no 
complaint,  and  to  which  he  applied  no  remedy  to 
prevent  its  increase.  But  in  the  summer  of  1793, 
finding  it  grew  suddenly  uneasy  he  became  alarmed, 
and  consulted  Sir   Walter  Farquhar  and  Mr.   Cline. 


*  Sir  Astley  Cooper. 


—  63  — 
The  tumor  was  then  of  uncommon  size,  reaching  to 
his  knees,  and  very  large  at  its  connexion  with  the  ab- 
domen. As  some  water  was  perceptible  at  the  lower 
part  of  the  tumor,  it  was  tapped  in  the  month  of 
November,  1793,  and  a  large  quantity  of  water  was 
drawn  off.  In  a  fortnight  after,  it  was  again  tapped 
and  three  quarts  of  water  were  evacuated  without  any 
sensible  diminution  of  the  swelling.  Six  weeks  after- 
wards, the  skin  over  the  tumor  having  inflamed  and 
shown  a  disposition  to  ulcerate,  the  tapping  was 
again  repeated,  Jan.  13,  1794,  when  six  quarts  of 
water  were  discharged.  Two  evenings  afterwards  he 
began  to  complain  of  a  pain  in  his  stomach  and  sore- 
ness in  the  abdomen,  and  in  the  tumor  on  pressure. 
He  passed  the  night  restlessly,  but  the  next  morning 
when  he  rose  he  seemed  in  better  health  and  spirits 
than  usual.  Soon  after  he  became  insensible,  and  ex- 
pired about  eleven  o'clock. 

Mr.  Cline  asked  me  to  accompany  him  to  inspect 
the  body.  We  found  the  abdomen  nearly  emptied  of 
all  the  moveable  viscera,  no  omentum  remaining  with- 
in its  cavity,  and  of  the  intestines  only  the  duodenum 
and  coecum.  Even  the  pylorus  was  drawn  down  so 
low  as  to  lie  upon  the  orifice  of  the  hernial  sac,  into 
which  all  the  onientum,  and  all  the  intestines,  except 
those  I  have  just  mentioned,  had  descended.  They 
were  all  uncommonly  loaded  with  fat,  and  slightly  in- 
flamed. The  hernial  sac  extended  nearly  as  low  as 
the  knee,  its   orifice  was  so  large  as  to  admit  my  hand 


—  64  — 

within  it.  Below  the  sac  appeared  a  separate  bag 
large  enough  to  hold  several  quarts  of  water,  which, 
by  its  containing  the  testicle,  proved  to  be  the  tunica 
vaginalis  testis." 

The  practical  questions  arising  from  the  con- 
sideration of  irreducible  hernia  are  those  of  treat- 
ment. Often  it  is  exceedingly  difficult  to  determine 
the  exact  conditions  of  contents.  If  omental  only,  a 
truss  may  be  fitted,  if  intestinal,  the  pressure  of  a 
truss  would  prove  dangerous.  A  small  loop  of  intes- 
tine may  be  concealed  in  omentum  and  not  easily 
detected.  If  the  truss  proves  painful,  it  should  be 
worn  with  great  caution,  or  better  omitted  entirely. 
When  a  hernia  becomes  irreducible,  it  is  almost  cer- 
tain to  grow  worse  steadily  and  endanger  the  life  of 
the  sufferer  constantly.  Modern  aseptic  surgery 
should  relegate  the  entire  class,  almost  without  excep- 
tion, to  operative  measures. 

STRANGULATED    HERNIA. 

When  the  constriction  of  any  portion  of  the  con- 
tents of  the  hernial  tumor  is  sufficient  to  impede  or 
impair  the  circulation  of  the  blood  and  thus  endanger 
the  nutrition  of  the  parts  enclosed;  to  arrest  the  pas- 
sage of  the  foecal  contents  through  the  intestinal 
canal,  the  hernia  is  called  strangulated.  Constitu- 
tional symptoms  speedily  supervene  and  unless  relief 
is  afforded  the  condition  is  one  of  extreme  danger. 

The  neck  of  the  sac  is  usually  the  seat  of  the  con- 


-  65  - 
striction.  It  may,  however,  occur  in  any  portion  and 
there  may  be  more  than  one  constricting  band.  The 
causes  of  strangulation  are  various.  Obstruction  may, 
and,  very  likely,  does  frequently  supervene  upon 
changes  in  the  circulation  and  nutrition  of  the  intes- 
tinal loop  within  the  sac.  The  venous  return  current 
impeded;  there  will  ensue,  even  in  an  old  hernia,  an 
increased  weight,  a  suspension  of  peristaltic  motion,  a 
retention  of  intestinal  contents,  resulting  in  an  over- 
distention  of  the  sac.  It  is  probable  that,  in  most 
instances,  the  changes  commence  within  the  sac, 
rather  than  in  the  constricting  part.  Once  com- 
menced, however,  they  mutually  react  to  the  injury  of 
both. 

As  generally  observed,  the  first  symptoms  are 
local  pain,  a  tumor  more  or  less  large,  if  none  existed 
before;  if  an  old  hernia,  a  tenderness  and  increase  of 
swelling,  a  dragging  weight,  and  a  sensation  of  un- 
easiness in  the  hypogastrium.  This,  sometimes,  be- 
comes so  severe  that  it  seems  as  if  a  cord  was  tied 
about  the  body.  The  mechanical  obstruction  to  the 
intestine  is  soon  followed  by  more  marked  nervous 
symptoms,  pain  and  restlessness  supervene  with  nausea 
and  vomiting;  this  may  be  accompanied  by  a  desire  to 
defecate,  and  straining  at  stool  results  in  the  passage 
of  little  except  flatus.  Sometimes  these  general  reflex 
nervous  symptoms  are  so  prominent  that  the  patient 
and  physician  both  may  fail  to  consider  the  cause  as 
one  of  obstruction  or  think  of  hernia. 

6   DD 


—  66  — 

If  unrelieved,  the  general  symptoms  become  more 
marked,  the  nervous  anxiety  pronounced,  the  pulse 
small,  hard,  quick,  the  temperature  somewhat  elevated, 
and  the  nausea  and  vomiting  severe.  There  is  a 
gaseous  distension  of  the  intestines,  giving  a  tense, 
tympanitic  abdomen.  The  vomiting  becomes  faecal 
and  no  gas  passes  the  anus. 

When  these  symptoms  have  become  marked  the 
obstruction  is  not  only  complete,  but  has  existed  longer 
than  is  consistent  with  safety.  Every  practitioner 
should  study  the  grouping  of  such  symptoms  and  be 
early  on  the  alert,  since  danger  increases  each  hour, 
almost  in  a  geometric  ratio.  The  intestinal  canal,  be- 
tween the  obstruction  and  the  stomach,  not  seldom 
the  stomach  even,  becomes,  by  degrees,  distended 
with  a  dark  brown  colored  fluid;  this  rapidly  under- 
goes fermentation  and  sets  free  gas  which  greatly  adds 
to  the  stretching  of  the  intestine,  causing  a  paralysis 
which  is  often  slow  in  recovering.  The  mucous  mem- 
brane is  deeply  congested,  the  villi  turgid  and  swollen, 
even  the  serous  coat  much  changed  in  color,  and  is 
often  punctated  or  striated  in  patches  of  deep  red. 
The  intestine,  on  the  contrary,  below  the  stricture  is 
decidedly  pale  and  contains  little  except  mucus. 

If  the  patient  remains  unrelieved,  uncontrollable 
retching  and  vomiting  may  ensue,  prostration  super- 
venes rapidly,  and  death  from  collapse  may  occur. 
Life  may  be  prolonged  until  the  constricted  portion 
of  the  intestine  ulcerates  and  the  intestinal  contents 
set  up  a  rapid  septic  peritonitis. 


-  67  - 

At  the  beginning  stage  of  prostration,  the  active 
nervous  tension  abates,  the  nausea,  especially  if  the 
patient  is  partially  narcotized,  lessens  or  disappears. 
This  should  not  quiet  the  attendants,  but,  on  the  con- 
trary, betokens  grave  changes,  a  depression  of  the 
vital  force,  from  which  the  patient  never  rallies.  The 
pulse,  before  full  and  rapid,  is  now  slower  and 
weak,  the  heart  contracting  with  little  force.  The 
cutaneous  surface  is  cooled  and  shrivelled,  the  hands 
and  feet  cold  and  wet;  the  expression  is  one  of 
anxiety  and  distress,  the  tongue  dry  and  brown.  The 
muscular  system  is  relaxed  and  the  urinary  secretion 
is  greatly  diminished. 

The  patient  may  continue  for  some  time  in  this 
state — the  very  threshhold  of  death,  pulseless,  scarcely 
seeming  to  breathe,  yet  with  unclouded  mental  vision 
and  able  to  converse,  a  slight  change  only,  and  death 
has  supervened. 

When  death  follows,  the  local  conditions  do  not 
present  changes  sufificiently  marked  to  have  caused 
such  a  result,  and  the  fatal  issue  is  very  probably 
dependent  upon  the  extreme  nervous  exhaustion,  or 
collapse. 

Although  local  pain  is  considered  a  sign  of 
peritonitis,  it  is  difficult  to  determine  the  inception  of 
the  peritoneal  inflammation.  It  is  often  local  with  a 
protective  layer  of  lymph  effused.  When  arising 
from  perforation,  the  pain  is  usually  severe,  and  death 
may  follow  from  the  shock  to  the  nervous  system,  but 
usually  from  rapid  infiltration,  as  a  septic  poisoning. 


—  68  — 

The  pathological  changes  of  the  contents  of 
the  intestine  are  of  interest.  The  vomitus,  at  first, 
appears  to  consist  chiefly  of  the  ingesta,  frequently  of 
the  substances  last  taken  into  the  stomach.  Then  the 
fluids  become  changed  in  color,  odor,  and  taste,  by 
being  mingled  with  the  biliary  secretions.  The  color 
changes  from  greenish  hue  to  brown  or  even  almost 
black,  and  later  the  odor  becomes  feculent;  the  well- 
known  stercoraceous  vomitus. 

Blood  cells  may  often  be  found  and  the  color  of 
the  serous  fluid  is  deepened  by  that  of  the  blood. 
Epithelium  is  constant,  often  in  patches,  and  the 
quantity  of  fluid  in  the  intestine  and  stomach,  owing 
to  the  impaired  venous  return  current,  is  often 
quite  beyond  expectation.  In  a  case  of  operation  for 
vulvulus,  where  I  easily  freed  the  intestine  and  had 
closed  the  wound,  as  the  ether  was  removed,  a  spas- 
modic continued  vomiting  ensued,  and  death  occurred 
from  impeded  respiration,  although  the  head  was 
carried  forwards  with  tongue  drawn  out  and  every 
effort  made  to  clear  the  throat.  It  was  estimated  the 
ejected  fluid  exceeded  two  quarts. 

There  is  usually  a  limited  quantity  of  serum  in 
the  sac  of  a  strangulated  hernia.  This  varies  accord- 
ing to  the  character  and  duration  of  the  constriction. 

At  first  it  is  pale  yellow,  clear  serum,  changes  in 
color,  and  later  becomes  turbid,  with  blood  cells  freely 
mingled,  even  to  the  production  of  small  clots;  the 
serum  may  then  become  like  dark  coffee.  Not  seldom, 


-  69  - 
there  is  to  it  an  odor  like  feces  and  it  would  be  inter- 
esting to  know,  if  tiie  fluid  is  not  infected  with  bacteria 
from  the  intestinal  contents,  escaped  through  the  im- 
prisoned walls.  It  is  probable  that  micrococci  are  in 
abundance. 

The  tissues,  covering  the  tumor,  exhibit  changes 
coincident  with  those  of  the  contents.  These  are 
more  marked  nearest  the  constriction  and  lessen  to- 
wards the  surface.  Violent  manipulation  of  the  mass 
may  and  often  does  cause  marked  changes  in  the  in- 
teguments; echymosis  of  the  connective  tissue,  oedema, 
and  redness  of  the  skin. 

In  strangulated  omental  hernia,  the  symptoms 
are  much  less  severe.  The  pain  is  often  inconsider- 
able, the  vomiting  not  marked,  and  the  abdominal  dis- 
tention not  pronounced.  The  intestinal  function, 
although  generally  inpaired,  is  not  suspended  and 
passages  from  the  bowel  are  obtained  with  greater  or 
less  difficulty.  When  fatal,  death  occurs  from  necrosis 
of  the  part  with  subsequent  general  infection. 

The  danger  from  strangulation  is  greater  in 
femoral  than  other  varieties,  since  the  constricting 
ring  is  less  yielding,  and  the  canal  generally  smaller. 
Small  recent  hernia  are  also  more  liable  to  strangula- 
tion and  more  easily  overlooked. 

A  variety  called  bubonocele,  vvhere  the  hernial 
tumor  is  retained  within  the  canal,  is  often  so  small  as 
to  escape  detection  unless  specially  sought  and  may 
be,  on  this  account,  all  the  more  dangerous. 


—  70  — 

Dr.  A.  H.  Wilson,*  of  Boston,  has  contributed  a 
valuable  paper  upon  the  subject.  He  narrates  a  case 
where  death  ensued  from  a  concealed  hernia  of  this 
character,  not  recognized  until  at  autopsy.  The  pos- 
sibility of  obstruction  arising  from  this  cause  should 
be  held  in  consideration. 

Strangulated  hernia,  unless  the  tumor  is  reduced, 
is  almost  always  fatal.  In  some  instances,  the  wall  of 
the  intestine  becomes  adherent,  a  small  slough  occurs, 
leaving  an  ulcerated  opening  through  which  a  small 
portion  of  the  fecal  matter  escapes,  the  larger  part 
running  its  natural  passage.  In  other  instances,  the 
incarcerated  loop  sloughs,  and  an  artifical  anus  is 
formed,  through  which  all  the  fecal  material  passes. 
Such  complication  may  result  in  hernia  of  the  rarer 
varieties.  Somewhat  recently  a  patient  entered  hospi- 
tal, with  constantly  recurring  fecal  dejections  escap- 
ing through  the  vagina.  About  two  weeks  previous 
she  had  been  delivered  with  great  difficulty  of  a  child, 
at  term,  with  a  shoulder  presentation.  It  was  not 
recognized  that  the  vagina  had  been  injured  until 
symptoms  of  obstruction  supervened.  After  some 
days,  fecal  dejections  came  from  the  vagina.  A  loop 
of  the  ilium  had  escaped  through  a  vaginal  rent,  be- 
come adherent,  and  sloughed.  As  death  seemed  im- 
minent from  starvation,  after  consultation,  an  attempt 
was  made  at  restoration  by  laparotomy.     The  general 


*Journal  of  the  American  Medical  Association,  Aug.   25, 
1883. 


—  71  — 

peritoneum  was  not  involved,  the  intestine  was  freed 
from  its  attachment  and  withdrawn.  The  ulceration 
included  about  three-fourths  of  the  circumference. 
The  edges  were  refreshed  and  reunited.  Unfortun- 
ately, however,  the  patient  sank  and  died  from  ex- 
haustion the  second  day. 

The  prognosis  of  strangulated  hernia  must  be 
determined,  from  the  foregoing  considerations,  to  be 
of  a  gravity  dependent  upon  the  character  of  the  con- 
striction and  the  time  since  it  first  ensued.  It  may  be 
accepted  that  there  are  few  dangers  to  which  the  race 
is  liable  that  become  so  fearfully  aggravated  by  delay. 


CHAPTER  VI. 

SURGICAL  PROCEDURES. 

Operative  Measures. — The  dangers  from  the  pro- 
per performance  of  the  operation  for  strangula- 
tion are  in  direct  ratio  to  the  above  factors.  "We 
have  never  known  an  instance  of  a  patient  dying 
in  consequence  of  the  bowel  being  Hberated  at 
too  early  a  period;  but  we  have  had  to  oper- 
ate upon  many  whose  chances  of  life  were  abso- 
lutely sacrificed  by  the  inexcusable  delay  which  had 
occurred  before  the  patient  was  submitted  to  the 
operation.  We  make  this  assertion  after  a  large  ex- 
perience, extending  over  many  years."*  The  state- 
ment of  this  eminent  surgeon  is  in  accord  with  the 
experience  of  most  operators.  It  is  now  generally 
conceded  that  the  danger  lies  not  in  the  operation, 
but  in  the  conditions  which  demand  it.  It  may  be 
accepted  that,  with  aseptic  precautions,  the  operation 
is  practically  safe.  In  an  experience  of  twenty  years, 
I  am  assured  I  have  not  had  a  single  fatal  case  where 
the  integrity  of  the  intestinal  canal  was  not  involved, 
I  have  repeatedly  removed  large  portions  of  the 
omentum  without  complication. 

In  this  respect,  hospital  statistics  as  such  are  of 
little  value.  The  cases  are  sent  in  late,  often  have 
been  sadly  neglected,  and  their  condition  rendered 


*  Birkett.     Opp.  cit. 


—  73  — 
much  worse  by  injudicious,  and  even  violent  attempts 
at  reduction. 

The  attendant  is,  at  first,  in  the  great  majority  of 
cases,  a  physician  little  experienced  in  operative  meas- 
ures and  much  valuable  time  is  lost  in  "  watching  the 
case,"  the  administration  of  drugs  and  leading  up,  not 
only  the  friends,  but  himself  to  the  conclusion  that 
the  case  is  involved  in  serious  danger. 

What  should  justly  precede  operative  measures  is 
a  question  of  important  consideration. 

First,  the  careful  differentiation  of  the  factors  in 
the  problem  presented.  This  will  notably  consist  of 
a  consideration  of  the  character  of  the  hernia  in  its 
anatomical  relations — its  kind  and  variety;  its  forma- 
tion and  duration;  the  constitutional  condition,  the 
state  of  the  tumor,  the  treatment  already  employed. 

The  dextrous  manipulation  of  a  hernial  tumor,  by 
which  it  maybe  displaced  from  its  abnormal  surround- 
ings, and  restored  to  a  normal  condition,  is  termed 
taxis.  It  seems  almost  universally  accepted  that  this 
is  a  simple  measure  and  should  be  resorted  to  without 
fear.  Generally,  when  the  physician  is  called,  it  is 
only  after  constitutional  symptoms  of  some  gravity 
have  supervened  and,  almost  always,  efforts,  more  or 
less  persistent,  have  been  made  at  reduction.  Often 
vomiting  is  persistent  and  the  tumor  is  swollen  and 
tender.  If  this  is  the  condition,  taxis  at  first  should 
not  be  attempted.  Place  the  patient  in  a  position  to 
relax   the   muscles;   on   back,  pelvis  elevated,  knees 


—  74  — 
flexed  and  tumor  lifted  so  as  to  relieve  the  dragging 
on  the  neck  of  the  sac  and  aid  displacement  by  gravity. 
Hot  applications  are  sometimes  of  value;  if  the  skin  is 
red  and  tense,  ice  may  be  kept  on  often  to  great  ad- 
vantage and  the  general  condition  improved  by 
hypodermic  injection  of  morphia.  Happily,  a  few 
hours  sleep  and  the  hernia  is,  so  to  speak,  self  re- 
duced. If  continued,  use  very  gentle  manipulation 
and  if  this  fail,  no  longer  delay  to  be  prepared  for 
surgical  interference.  Thus  ready,  thoroughly  anaes- 
thetise your  patient.  This  is  of  the  first  importance 
in  the  proper  use  of  taxis,  since  it  canses  a  relaxation 
of  the  tissues  obtainable  in  no  other  way,  and  enables 
the  operator  to  avail  himself  of  every  possible  ad- 
vantage of  position,  of  both  the  tumor  and  the  sur- 
rounding parts.  With  much  tact  and  care,  gently  en- 
deavor to  reduce  the  tumor,  remembering  that  a  con- 
stricted intestine,  after  twenty-four  hours,  may  be  easily 
lacerated.  If,  for  any  reason,  from  the  use  of  taxis, 
or  violence  of  accidental  character,  it  is  feared  that  in- 
jury to  the  sac,  or  its  contents  has  ensued,  let  opera- 
tive measures  be  at  once  undertaken.  Upon  opening 
the  sac,  if  the  intestine  is  so  discolored  as  to  cause  it 
doubtful  if  necrosis  has  not  already  taken  place,  pull 
down  the  loop  beyond  the  line  of  constriction,  after 
the  opening  has  been  made  sufficiently  large,  and 
carefully  observe  if  the  circulation  is  slowly  restored. 
This  assured,  it  is  safe  to  return  it  and  close  the  wound. 
If  the  intestine  is  injured,  so  that  its  integrity  is  in  part, 


—  75  — 
or  entirely  destroyed,  then  give  your  patient  the  ad- 
vantages which  modern  surgery  has  so  marvelously 
wrought  in  the  treatment  of  wounds  of  the  intestine. 
The  omentum,  as  well  as  the  intestine,  often  suffers  in- 
jury in  efforts  at  reduction,  or  by  violence.  This,  of 
course,  is  less  important,  but  not  rarely  will  it  become 
wise  to  remove  the  enclosed  portion,  as  a  measure 
much  safer  than  to  venture  its  return.  I  have  often 
done  this  with  seeming  impunity,  certainly  without 
complication  or  danger. 

The  hernial  sac  may  suffer  from  violence,  either 
in  being  torn  from  its  attachments  and  the  tumor  with 
its  peritoneal  investment  returned  en  mass,  or  the  sac 
itself  may  be  ruptured  under  pressure,  and  the  con- 
tents still  further  displaced  into  the  subjacent  parts. 

In  the  first  instance,  it  is  very  probable  that  the 
constriction  of  the  neck  of  the  sac  will  still  continue 
to  surround  and  incarcerate  the  contents.  Such  cases 
are  undoubtedly  very  rare,  yet  sufficiently  numerous 
in  the  history  of  surgery  to  render  the  study  of  such 
conditions  interesting.  They  will  be  less  often  met 
with  hereafter,  since  the  teachings  of  modern  surgery 
cause  operative  measures  to  be  less  feared  and  conse- 
quently efforts  at  taxis  will  not  be  as  persistent.  If 
there  is  evidence  that  such  a  complication  has  re- 
sulted, operative  measures  should  be  at  once  under- 
taken, and  even  laparotomy  may  be  a  measure  to  be 
wisely  considered. 

When  the  sac  has  been  ruptured  and  its  contents 


-  76  - 

in  part  displaced,  it  may  be  difficult  to  determine  the 
exact  condition,  especially  if  the  surgeon  has  not  pre- 
viously seen  the  patient.  The  sac  will  be  noticeably 
less  tense  and  the  feel  of  resistance  less,  but  the  all- 
important  symptoms  of  obstruction  remain,  and  when 
this  is  the  case,  operation  must  not  be  delayed.  It 
may  even,  after  the  sac  has  been  opened,  be  at  times 
difficult  to  determine  the  exact  relations  of  the  parts, 
but  these  must  be  carefully  differentiated,  since  life 
itself  will  depend  upon  a  proper  restoration  to  the 
normal  condition.  Divide  freely,  pull  down  the  in- 
testine and  ascertain  the  exact  point  of  exit  point 
from  the  abdominal  cavity;  thus  the  opening  or  neck 
of  the  sac  is  determined,  and  then  there  will  be 
little  further  difficulty  in  enlarging  it  and  restoring 
the  intestinal  contents.  This  done,  as  before  re- 
commended, dissect  out  the  sac  entire;  often  certain 
portions  of  the  surrounding  tissues  have  also  been  so 
much  injured  as  to  involve  their  integrity,  and  these 
also  should  be  cut  away. 

Somewhat  recently,  I  operated  upon  a  strangulat- 
ed hernia  of  three  days'  duration.  The  intestine, 
fortunately,  was  surrounded  by  omentum,  and  its  in- 
tegrity not  destroyed,  but  prolonged  taxis,  the  day  pre- 
vious to  operation,  had  resulted  in  not  only  marked 
injury  to  the  sac,  but  the  tissues,  for  a  considerable 
distance,  were  echymosed  and  so  devitalized  that  the 
dissection  was  carried  several  lines  outside  the  sac 
and  removed  together  with    a  considerable  piece  of 


—  11  — 

omentum.  Recovery  was  rapid,  and  the  cure  at  time 
of  writing  remains  complete. 

In  the  chapter  upon  the  formation  of  the  peri- 
toneal sac,  it  was  shown  that  it  may  rarely  be  double 
or  mutiple,  and  this  complication  should  be  borne  in 
mind  in  the  reduction  of  a  hernial  tumor.  The  con- 
tents may  pass  a  stricture  and  enter  the  abdominal 
parietes,  only  to  remain  still  without  the  abdominal 
cavity,  the  upper  portion  of  the  sac  remaining  as  a 
pouch  with  constriction  at  its  inner  orifice.  Symptoms 
of  obstruction  will  continue,  and  these  should  deter- 
mine upon  operative  procedures. 

In  all  the  foregoing  conditions,  there  can  be  but 
one  rule — never  assume,  but  determine  upon  positive 
knowledge  the  actual  conditions.  When  in  doubt, 
consider  it  as  a  sacred  duty  you  owe  your  patient  to 
give  him  the  benefit  of  it,  and  if  solved  in  no  other 
way,  by  resorting  to  operative  interference. 

For  a  long  period  the  profession  generally  have 
held  that  the  operation  of  cutting  is  one  of  such  seri- 
ous moment  that  it  should  be  undertaken  only  as  a 
last  resort.  This  belief  seems  to  have  arisen  from  the 
wretched  results  which  have  followed  the  generally 
delayed  operation.  Certainly,  it  is  not  the  teaching  of 
the  early  masters. 

Sir  Astley  Cooper  recognized,  even  in  his  day, 
when  the  lack  of  anaesthetics  and  of  the  requisite 
knowledge  of  proper  wound  treatment  rendered  the 
operation  truly  formidable,  the  fatal   error  of  delay. 


-  78  - 

''The  operation,  if  well  performed  in  an  otherwise 
healthy  person,  is  attended  with  little,  if  any,  danger, 
and  it  is  therefore  natural  to  inquire  why  it  has  so 
frequently  been  followed  with  the  death  of  the  patient. 
The  great  reason  of  want  of  success  in  this  operation 
is  its  being  performed  too  late,  so  that  the  protruded 
contents  have  proceeded  to  a  state  of  gangrene,  or  so 
nearly  approaching  to  the  gangrenous  condition,  that 
the  long  inflammed  parts  are  unable  to  recover 
their  natural  functions;  or  else  that  the  inflammation 
has  extended  to  the  viscera  in  the  cavity  of  the  abdo- 
men, continuing  the  consequence  of  the  disease  after 
the  stricture  which  caused  it  has  been  removed.  It 
cannot  be  too  much  lamented  or  condemned,  that  so 
much  time  is  commonly  lost  before  the  operation  is 
performed.  To  reduce  the  hernia,  trial  after  trial  is 
made,  the  same  means  are  often  repeated,  the  tumor, 
by  being  often  compressed,  becomes  excessively  ten- 
der, so  that  the  mere  cessation  of  the  efforts  at  reduc- 
tion gives  a  comparative  ease,  which  flatters  the  pa- 
tient and  his  medical  attendant  that  a  part  of  the 
tumor  has  gone  up;  hopes  are  still  entertained  that 
an  operation  may  be  avoided,  till  the  rapid  progress 
of  the  symptoms  of  danger  points  out  the  fatal  error 
of  delay,  and  when  the  operation  is  performed,  too 
clearly  demonstrates  the  impossibility  of  success."* 
What  more  graphic   picture  could  be  drawn  to- 

*0p.  cit. 


—  79  — 
day  of  the  fatal  errors  of  delay  than  by  this  great 
master  of  nearly  a  century  ago !  The  sooner  this 
error  is  eradicated  from  the  medical  thought,  the  bet- 
ter. Then  shall  we  discover  upon  what  fallacies  we 
have  founded  our  opinions!  If  I  write  for  no  other 
good  than  to  bring  the  question  of  operative  measures 
anew  under  a  discriminating  judgnient,  I  shall  not 
have  labored  in  vain.  When  the  errors  of  omission 
are  judged  equal  to  those  of  commission,  then  the 
serious  responsibility  of  the  advisor  will  be  viewed  in 
a  new  but  just  light. 

HERNIOTOMY. 

There  may  arise  occasions  where  the  necessity  of 
operative  intereference  permits  only  a  very  limited 
preparation.  Under  these  conditions,  the  operation 
may  be  successful  by  the  use  of  only  knife  and 
director,  or  even  without  this  latter  instrument. 
However,  it  is  always  far  better  to  have  trained  as- 
sistants, if  possible,  and  to  make  provisions  for  con- 
tingencies. 

The  instruments  required  are  an  ordinary  scalpel, 
grooved  director,  several  pairs  of  forceps,  including 
dissection,  artery,  and  tenaculum  forceps;  a  bistoury 
with  blunt  point,  commonly  called  a  hernia  knife,  that 
devised  by  Sir  Astley  Cooper  is  still  a  favorite;  needles 
and  reliable  catgut  or  tendon. 

The  patient  when  fully  under  the  influence  of  an 
anaesthetic  is  placed    upon  'a  table  in   a   good  light. 


—  8o  — 

The  head  is  slightly  elevated,  the  legs  nearly  paralle 
with  the  body  and  the  feet  in  a  chair.  An  inflated 
rubber  receptacle  is  placed  under  the  hips  to  conduct 
the  irrigating  fluid  into  a  pail.  The  bladder  is 
emptied  and  the  parts  carefully  shaved  and  cleansed 
with  a  solution  of  yg^oir  rnercuric  bichloride. 

Commencing  at  the  upper  part  of  the  external 
abdominal  ring,  extend  the  incision  downwards  over 
the  tumor  quite  to  its  base  unless  very  large.  It  is 
better  not  to  try  to  differentiate  the  layers  composing 
the  coverings  of  the  sac,  since  they  are  often  much 
changed  and  will  be  quite  sure  to  confuse,  rather  than 
aid  the  inexperienced. 

Divide  the  fascia  upon  a  director,  or  lifted  by 
forceps,  with  care;  the  only  sure  anatomical  guide  in 
the  male  will  be  the  fibres  of  the  cremaster,  but  these 
are  of  little  importance.  When  the  sac  is  exposed,  by 
grasping  the  tumor  posteriorly,  fluid  is  generally  per- 
ceived distending  it  under  the  line  of  dissection. 
Also,  when  pinched  between  the  thumb  and  finger, 
the  surfaces  of  the  sac  may  be  made  to  glide  upon 
each  other;  generally  there  is  not  much  difficulty  in 
determining  the  sac.  Through  a  small  opening  made 
in  it,  insert  the  director,  and  divide  freely  downwards, 
and  upwards  to  the  external  ring.  In  small  inguinal 
hernise,  the  incision  should  be  made  parallel  with 
Poupart's  ligament,  from  the  internal  to  below  the  ex- 
ternal ring;  in  femoral  hernise,  on  the  inner  side  or 
over  the  crural  ring,  usually  in  a  vertical^  direction. 


The  sac  in  recent  hernise,  is  vascular  and  of  a  bluish- 
white  glistening  color;  in  old  herniae,  it  is   often  thick 
and  opaque.     After  snipping  the  sac,  the  division  is 
first  made  from  above  downwards,  since  the   base  of 
the  sac  is  usually  partly  filled  with  serum,  more  or  less 
changed,  which  serves  as  a  protection  to  the  intestine. 
The    finger    is    introduced    into   the  sac    and  carried 
gently  to  the  ring.     The  exact  diagnosis  of  the   con- 
ditions can  now  be  made,  as  well  as  correct  knowledge 
of  contents.  •  The  obstruction  is  usually  found  at  the 
upper  border  of  the  sac  near  the   internal  ring.      The 
finger  is  generally  the  only  director   required  and  by 
far    the    best,     since     it     teaches    the    constriction, 
its    characteristics   as   to   firmness,    extent    of    thick 
ness    and    often    the    location    of    the    neighboring 
arteries.      The  probe-pointed  bistoury  is  carried  on 
the   finger   flatwise   through   the   stricture,    which    is 
divided  by  turning  the  edge  of  the  knife  against  it.    I 
have  often  been  surprised  to  note  how  little  of  the 
firm  tense  band  it  is  necessary  to  divide.     Usually  a 
few   fibres  yield  with   a  peculiar  grating  sound;    an 
incision  only  a  line  or  two   in   depth  is  required   and 
the  constriction  is  freed.     Emphasis  has  been  made 
very   properly   upon   the    possibilities   of  cutting  the 
epigastric  artery,  but  I  cannot  help   feeling  that  this 
danger  is  greatly  overestimated.      Fortunately,  I  have 
never  seen  it  injured;  but  should  this  happen,  it  is  not 
a  very  important   vessel  and  can  be  easily  secured. 
The  old  rule,  based  upon  very  many  special  dissec- 


7    DD 


—     82     — 

tions,  is  a  wise  one,  to  cut  directly  upwards,  since, 
in  an  oblique  inguinal  hernia,  the  artery  is  internal  to 
the  neck  of  the  sac,  in  direct,  external  and  at  times 
the  canal  is  so  much  altered  that  it  may  be  difficult  to 
determine  the  relation.  Various  modifications  of 
sheathed,  narrow,  cutting  instruments  have  been  rec- 
ommended as  improvements  upon  the  herniotomes. 
A  very  ingenious  hernia  knife  has  been  devised  by 
Dr.  Allis,  of  Philadelphia.  It  is  probe-shaped,  with  a 
moveable  sheath,  directed  by  a  nut,  to  conceal  or  ex- 
pose the  cutting  edge  as  desired.  The  best  which  I 
have  seen  is  one  by  Dr.  Joseph  H.  Warren,  of  Boston, 
which  combines  the  director  and  divider  in  a  single 
instrument.  By  pushing  a  thumb-screw  in  the  handle, 
a  fine  saw  is  carried  through  the  groove  and  the 
stricture  sundered  in  a  very  safe  manner.  Having 
freed  the  constriction,  the  contents  of  the  sac  are 
carefully  examined.  If  lymph  has  been  effused,  and 
adhesion  formed,  separate  gently  and  wash  carefully 
in  the  warm  sublimate,  before  returning  the  intestine 
into  the  abdominal  cavity;  examine  as  to  the  returning 
circulation  in  the  bowel,  integrity,  etc.  If  omentum 
also  makes  up  a  part  of  the  contents,  gently  unfold  its 
compressed  layers;  if  its  integrity  is  at  all  doubtful, 
remove  after  having  sutured  across  above  the  line  of 
division.  Thus  secured,  I  have  never  seen  trouble 
from  hemorrhage.  It  is  so  vascular  that  ligation  of 
the  many  bleeding  points  may  be  very  troublesome. 
Having   returned    the    abdominal   contents,   the 


subsequent  treatment  of  the  wound  is  to  be  conducted 
upon  precisely  the  same  conditions  as  if  the  operation 
had  been  undertaken  to  cure  a  non-strangulated  re- 
ducible hernia.  The  factors  of  cure  for  every  reason, 
however,  are  less  favorable,  since  the  general  and 
local  conditions  are  often  of  the  gravest  character. 

Until    the    introduction    and    establishment    of 
modern  wound  treatment,  upon  a  basis  of  true  science, 
the  surgical  treatment  of  hernia  was  a  problem  little 
if  any  modified  or  improved  by  the  experience   of  a 
century.     The  dread  of  inflammation  and  the  terrible 
results   supervening,  when  its  locality  was  withm   the 
abdomen,  gave  to  the  name  of  peritonitis  a  significa- 
tion of  fear  unknown  to  the  younger  members  of  the 
profession   of   to-day.      Since   the   teachings   of    Mr. 
Lister,  and  the  now  well  formulated  facts  of  wound  in- 
fection, the  revolutionizing  of  surgery  is  nearly  complete. 
In  no  operation  is  an  aseptic  condition  of  the  wound 
more  important  than  in  hernia;  it  is  to  be  considered 
as  a  modified  laparotomy,  which   involves  always  the 
possibility  of  a  peritoneal  infection.     In  Mr.  Birkett's 
masterly  article  upon  hernia,  in  Holmes'  Revised  Sys- 
tem of  Surgery,  published  in  1881,  the  treatment  of 
the  wound,  after  operation  for  strangulation,  is  dis- 
missed as  follows:     "  The  structures  which  have  been 
cut  and  disturbed  by  the  cutting  operation  should  be 
placed  in  relation  to  each  other,  and  the  divided  edges 
of  the  integuments  brought  together  by  sutures.     The 
number  required  may  be  left  to  the  discretion  of  the 


~  84  - 

operator,  but  no  more  need  be  used  than  sufficient  to 
keep  the  upper  two-thirds  of  the  wound  united.  For 
it  is  always  advantageous  to  leave  'an  opening  at  the 
lowest  end  to  allow  of  the  escape  of  the  blood  and 
discharges.  A  piece  of  wetted  or  dry  lint  may  be 
placed  over  the  incision,  and  a  pad  of  folded  lint  is 
adjusted  over  it  by  some  surgeons.  However,  a 
bandage  is  not  required  in  every  case,  nor  is  it,  on 
any  account,  essential." 

Warren,  writing  in  1882,  states:  "The  wound  is 
now  drawn  together  by  sutures  and  the  dressing  com- 
pleted by  adhesive  plaster,  compress,  and  a  spica 
bandage.  Morphine  or  opium  should  be  administered^ 
both  to  secure  rest  and  also  to  secure  the  patient 
against  that  inflammation,  always  to  be  dreaded, '  peri- 
tonitis.'" 

In  1884,  Mr.  John  Wood  writes:  "  The  edges 
of  the  wound  are  then  brought  together  with  sutures, 
sufficiently  close,  a  drainage  tube  being  placed  along- 
the  bottom  and  out  at  the  lower  end  of  the  wound, 
and  the  parts  dressed  and  well  padded  with  carbolized 
gauze,  tow,  or  cotton  wool,  the  whole  secured  with  a 
spica  bandage  and  a  support  to  the  scrotum,  *  *  * 
In  favorable  cases,  with  little  damage  to  the  hernial 
contents,  I  have  for  many  years  been  in  the  habit,  at 
the  end  of  the  operation  for  the  relief  of  strangulation, 
both  in  inguinal  and  crural  hernia,  of  taking  away  the 


*Vol.  I  J,  American  edition,  p.  707. 


-  85  - 
sac,  after  tying  it  with  catgut,  and  closing  the  tendin- 
ous hernial  opening   by  my  wire  operation,  and  with 
the  best  results,  both  without  and  with  the  spray   and 
^auze  treatment." 

These  quotations  from  the  leading  special  authors 
xipon  hernia,  who  have  written  within  the  very  late 
years,  may  be  accepted  as  the  expression  of  the  gen- 
eral practice  of  to-day.  Many  other  more  recent 
authors  might  be  cited  who  repeat  similar  instructions 
but  these  teachers  have  devoted  many  years  of  careful 
investigation  to  the  subject  and  yet  they  wrote  as 
above,  long  after  the  establishment  of  antiseptic 
wound  treatment. 

TREATMENT  OF  THE  WOUND  AFTER  REDUCTION  OF 
THE  STRANGULATED  PARTS. 

With  one  or  two  fingers  of  the  left  hand,  inserted 
into  the  base  of  the  sac,  carefully  separate  it  from  its 
adhesions  to  the  surrounding  parts,  quite  to  the 
internal  ring.  Having  thus  freed  the  sac,  quite 
within  the  internal  ring  it  should  be  drawn  gently 
but  firmly  downward  and  put  on  tension  by  an 
assistant.  It  is  then  sewed  across  its  neck,  in  even 
continuous  double  suture,  with  tendon,  and  ex- 
cised.    The  peritoneum  is  gently  pushed  within  the 

*J.  H.  Warren,  Boston,  2nd  Edition,  p.  219. 
f  J.  Wood,  Vol.  V.     International  Encyclopedia  of  Surg- 
ery, page  II35- 


—  86  — 

internal  ring,  and  the  latter  is  slightly  refreshed  with 
the  edge  of  the  bistoury.  The  lower  and  inner  border 
of  the  ring  is  transfixed  by  a  needle,  with  eye  near 
the  point,  armed  with  tendon. 


Fig.  7. 

Dr.  Marcy's  Needle,  used  in  the  application  of  the  deep  double  con- 
tinuous animal  suture.  The  eye  is  large  and  smooth,  and  there 
extends  in  both  directions  a  slot  to  catch  and  hold  the  thread 
from  slipping.  The  point  and  inner  side  is  rounded  to  prevent 
cutting  of  the  tissues. 

It  is  guided  upon  the  index  finger  of  the  left 
hand,  which  is  retained  in  the  ring.  The  needle  is 
unthreaded,  threaded  with  the  opposite  end  of  the 
suture  and  withdrawn.  Stitches  are  repeated,  about 
one-third  of  an  inch  apart,  in  this  way,  and  the 
inguinal  ring,  thus  obliquely  closed,  is  reformed,  but 
not  shortened,  narrowing  down  upon  the  cord,  in  the 
male,  as  closely  as  deemed  safe,  and  not  impair  its 
integrity.  Throughout,  it  is  protected  by  the  finger, 
during  the  application  of  the  sutures. 

A  second  and  more  superficial  layer  of  sutures 
is  made,  in  the  same  manner,  through  the  fascia,  the 
last  stitch  knotted,  and  cut  close.      The  skin   is  co- 


—  87   - 

apted  also  by  a  buried  suture.  This  is  best  effected 
by  the  use  of  a  straight,  or  slightly  curved  Hagerdorn 
needle,  carried  from  within,  through  the  deeper  layer 
of  the  skin,  from  side  to  side.  Thus  the  edges  of  the 
skin  are  evenly  co-apted  without  the  vestige  of  a 
stitch  in  sight.  The  surfaces  are  carefully  dried  and 
dusted  with  iodoform.  Iodoform  collodion  is  freely 
applied,  into  which  are  incorporated  shreds  of  cotton. 
The  operation  is  conducted  under  irrigation  with  the 
greatest  care  to  preserve  the  wound  in  an  aseptic 
condition.  This  assured,  drainage  is  not  necessary. 
In  my  earlier  operations,  I  reduced  the  drainage  to 
the  minimum,  by  the  introduction  of  a  few  parallel 
placed  horse-hairs.  Even  these,  however,  I  have 
omitted  for  some  years.  Coapted  surfaces,  held 
aseptically  at  rest,  readily  tolerate  the  limited  effusion 
which  is  utilized  in  the  processes  of  local  repair.  The 
elimination  of  the  drainage  tube  renders  the  complete 
closure  of  an  aseptic  wound  possible,  and  prevents  its 
further  extraneous  contamination.  Repair  ensues  as 
in  a  subcutaneous  wound.  The  advantage  of  this 
method  in  the  treatment  of  the  wound  is  the  assurance 
of  non-infection.  By  every  method  of  antiseptic 
dressing  with  drainage,  all  surgeons  have  admitted 
the  great  difficulty  and,  in  children,  the  well-nigh  im- 
possibility of  retaining  the  wound  aseptic. 

The  advantages  of  resection  of  the  sac,  as  com- 
pared w4th  other  methods  of  its  disposition  will  be 
discussed  in  a  subsequent  chapter. 


—  88  — 

In  congenital  hernia,  it  must  be  remembered,  that 
the  sac  is  the  dilated,  non-closed  process  of  the  peri- 
toneum which  descended  to  form  the  investment  of 
the  testicle.  Under  these  conditions,  the  sac  requires 
different  treatment.  It  is  sewed  across  to  form  the 
tunica  vaginalis  testis.  The  suturing  is  continued 
upwards  to  close  in  upon  the"  cord  with  its  vessels, 
and  then  narrowed  at  its  abdominal  outlet,  to  prevent 
pouching  of  redundant  peritoneum  and  excised.  The 
subsequent  steps  of  the  operation  are  conducted  as  in 
non-congenital  hernia. 


CHAITER  VII. 

FEMORAL  HERNIA. 

The  superficial  fascia  of  the  thigh  is  composed  of 
two  layers.  The  thick,  dense,  upper  layer  is  continu- 
ous with  the  fascia  above,  over  Poupart's  ligament, 
and  downwards  with  the  connective  tissue  layer  cover- 
ing the  thigh.  Enclosed  between  it  and  the  deep  layer, 
are  situated  the  cutaneous  vessels,  nerves,  and  the 
lymphatic  inguinal  glands.  The  deep  layer  is  a  thin, 
but  dense  membrane,  is  closely  adherent  above  to  the 
lower  margin  of  Poupart's  ligament,  and  about  one 
inch  below  is  closely  united,  in  its  circumference,  to 
the  saphenous  opening  in  the  fascia  lata.  It  blends 
with  the  posterior  border  of  the  sheath  of  the  femoral 
vessels.  In  this  locality,  rt  has  been  sometimes  de- 
scribed as  the  cribriform  fascia,  since  it  is  perforated 
by  the  internal  saphenous  vein  and  numerous  blood- 
vessels and  lymphatics,  giving  to  it  sieve-like  open- 
ings. 

The  fascia  lata,  in  a  dense,  connective  tissue 
layer,  forms  a  uniform  investment  over  the  entire 
upper  portion  of  the  thigh.  The  passage  of  the  inter- 
nal saphenous  vein  gives  the  name  to  the  opening 
through  which  this  vessel  penetrates.  The  fa^^cia,  on 
the  outer  side  of  the  opening,  is  called  the  iliac  por- 
tion. It  extends  from  the  anterior  superior  spine  of 
the  ilium  downward,  over  the  anterior  group  of  the 


Fig.  8. 
Femoral  Hernia,  Superficial  Dissection. — Gray. 


—  91  — 
muscles  of  the  thigh;  is  attached  the  whole  length  of 
Poupart's  ligament  internally,  as  far  as  the  spine  of  the 
pubes,  and  joins  in  the  pectineal  line  with  Gimbernat's 
ligament,  where  it  blends  with  the  pubic  portion.  It 
is  reflected  in  an  arched  margin  downwards  and  out- 
wards from  the  spine  of  the  pubes,  forming  the  outer 
boundary  of  the  saphenous  opening.  This  has  been 
described  as  the  femoral  ligament  of  Hey,  and  has 
also  been  called  the  falciform  process  of  the  fascia 
lata.  It  has  a  well-defined,  curved  margin  and  is  ad- 
herent to  the  sheath  of  the  femoral  vessels.  The 
pubic  portion  of  the  fascia  lata  is  its  continuation  upon 
the  inner  side  of  the  saphenous  opening,  and  lies  be- 
neath the  sheath  of  the  vessels  to  which  it  is  attached. 
The  opening,  through  which  the  internal  saphenous 
vein  thus  obliquely  passes  to  join  the  femoral,  is  oval, 
measures  about  an  inch  anid  a  half  in  length,  and  half 
an  inch  in  breadth.  The  inner  boundary  is  less  well- 
defined  than  the  outer,  since  it  is  behind  the  level  of 
the  femoral  vessels. 

Upon  extension  of  the  limb,  or  rotating  it  out- 
wards, the  edge  of  the  opening  will  be  rendered  tense. 
Flexion  and  inversion  of  the  limb  relaxes  it,  a  fact  to 
be  borne  in  mind  when  attempting  the  reduction  of  a 
femoral  hernia. 

In  the  study  of  inguinal  hernia,  Poupart's  liga- 
ment was  described  as  the  lower  border  of  the  apon- 
eurosis of  the  external  oblique  muscle,  stretching 
across,  in  a  strong,  tendinous  band,  between  the   an- 


Fig.  g. 

Femoral  Hernia,  showing  Fascia  Lata  and  Saphenous  Opening 
— Gray. 


—  93  — 
terior  superior  spine  of  the  ilium,  to  the  spine  of  the 
OS  pubis  and  the  pectineal  line  It  is  slightly  curved, 
with  convexity  downwards.  The  posterior  border  has 
an  arched  form  towards  the  pubes,  in  consequence  of 
the  expanded  portion  which  is  fixed  into  the  pectineal 
line.  This  was  called  the  crural  arch  by  Gimbernat. 
We  are  indebted  to  this  distinguished  Spanish  surgeon 
for  the  first  accurate  description  of  the  parts,  pub- 
lished in  Madrid,  in  1793.  The  attachment  into  the 
pectineal  line,  which  so  greatly  strengthens  the  sup- 
port of  the  ex'ternal  oblique,  is  now  generally  called 
Gimbernat's  ligament.  The  space  between  the  crural 
arch  and  the  bone  is  almost  entirely  occupied  by  the 
parts  which  descend  from  the  abdomen.  On  the 
outer  side  are  the  psoas  and  iliac  muscles.  On  the 
inner  side,  are  the  femoral  vessels  inclosed  in  a  sheath. 
The  oval-shaped  opening,  for  the  passage  of  the 
vessels,  is  the  crural,  or  femoral  canal.  Through  this 
opening,  the  abdominal  contents  escape  in  femoral 
hernia.  The  upper  border  of  the  canal  is  called  the 
femoral  ring,  and  is  continuous  with  the  cavity  of  the 
abdomen.  It  is  larger  in  the  female  than  in  the  male, 
(a  possible  reason  for  hernia  being  more  common  in 
women)  and,  in  its  large,  transverse  diameter,  measures 
about  one-half  an  inch.  In  front,  it  is  bounded  by 
the  deep  crural  arch  of  Poupart's  ligament,  behind  by 
the  pubes  and  the  deep  portion  of  the  fascia  lata,  in- 
ternally by  Gimbernat's  ligament,  the  conjoined  ten- 
don, the  transversalis  fascia,  and  the  deep  crural  arch; 


—  94  —  ' 
externally,  by  the  femoral  vessels  enclosed  in  their 
sheath.  Poupart's  ligament  separates  the  femoral 
from  the  internal  portion  of  the  inguinal  canal;  directly 
above  it,  lies  the  spermatic  cord,  with  its  vessels,  in 
the  male,  and  this  may  be  divided  in  the  operation  for 
strangulated  femoral  hernia.  The  epigastric  artery 
lies  across  the  upper  and  outer  angle  of  the  ring,  and 
is  endangered  by  cutting  in  this  direction.  Upon  the 
outer  side  of  the  ring  is  the  femoral  vein.  The  ring 
is,  as  it  were,  bounded  in  all  directions  by  vessels,  ex- 
cept posteriorly  by  the  ossa  pubis,  and*  internally  by 
Gimbernat's  ligament. 

The  obturator  artery  holds  an  important  relation 
to  the  femoral  ring,  when  it  arises,  by  a  common 
trunk,  with  the  epigastric  artery.  This  is  the  more 
important,  since  this  is  the  condition  in  every  three 
or  four  individuals.  Occasionally,  the  vessel  curves 
along  the  margin  of  Gimbernat's  ligament  as  it  passes 
to  the  obturator  foramen  and,  when  this  occurs,  it  is 
very  likely  to  be  divided  in  the  operation  for  a 
strangulated  femoral  hernia. 

A  delicate  layer  of  connective  tissue  closes  the 
femoral  ring,  and  is  described  by  M.  Cloquet  as  the 
septum  crurale.  It  is  a  slight  protection  to  a  hernral 
protrusion;  a  small,  lymphatic  gland  usually  lies  be- 
tween it  and  the  peritoneum.  It  is  perforated  by 
numerous,  small  openings  for  the  passage  of  lymphatic 
vessels  and  serves  as  much  for  their  connection  and 
support,  as  for  closure  of  the  ring.     Beneath  this  sep- 


Fig.   io. 

FemoranHernia.     Iliac  Portion  of  Fascia  Lata  Removed,  and  Sheath 
of_Femoral  Vessels  and  Femoral  Canal  Exposed.— Gray. 


Fig.  II. 


Hernia.  The  Relations  of  the  Femoral  and  Internal  Abdomi- 
nal Rings,  seen  from  within  the  Abdomen,  Right  Side^ 
— Gray. 

The  Hernial  Sac  and  parts,  the  subject  of  this  drawing,  were 
discovered  in  the  course  of  a  dissection.  The  tumor  did 
not  present  those  external  indications  that  led  to  a  suspi- 
cion of  its  existence  until  the  superficial  and  cribriform 
fascia  had  been  cut  through.  The  engraving  was  made 
from  a  cast  and  drawing  of  the  parts  taken  by  Mr.  E. 
Wilson,  and  is  well  adapted  to  show  the  parts  prior  to 
their  alterations  by  disease.  The  sac  is  denuded  of  its 
fascia  propria. — Warren. 

a  a,  upper  layer  of  the  iliac  portion  of  fascia  lata;  b  b,  pubic 
portion  of  the  same  fascia  forming  the  floor  of  the  femoral 
fossa;  c,  falciform  process  and  portion  of  the  border  of  the 
saphenous  opening;  d,  external,  or  semi-lunar,  portion  of 
the  same  border;  e,  Burns'  ligament,  or  pubic  portion  of 
the  arch  formed  by  the  border  of  the  same  opening;  /,  in- 
ferior pillar  of  the  external  abdominal  ring;  g,  spermatic 
cord;  h,  saphenous  vein;  i,  hernial  tumor. 

The  last  two  paragraphs  above  refer  to  Fig.  13,  page  104. 
They  were  inserted  under  Fig.  11  by  mistake. 


—  97  — 

turn,  a  layer  of  fatty  tissue  is  usually  found,  lying  di- 
rectly upon  the  peritoneum.  This  is  important, 
chiefly,  since  it  might  be  mistaken,  in  a  hernial  pro- 
trusion, for  omentum. 

It  is  easily  understood  from  a  study  of  the  an- 
atomy of  the  parts,  that  the  femoral  ring,  although  re- 
enforced  and  protected  in  such  a  marvellous  manner, 
must  be  a  weak  point  in  the  abdominal  wall.  By  con- 
genital defect,  in  laxity  of  tissue,  or  long-continued 
pressure,  the  peritoneal  covering  over  the  ring  becomes 
pouched,  and  a  lodgement  of  abdominal  contents 
serves  as  a  wedge  to  force  open  the  canal.  The 
greater  size  of  the  canal  in  woman,  together  with  the 
firmer  character  of  the  inguinal  ring,  renders  this 
variety  of  hernia  more  common  in  the  female. 

The  abdominal  contents  which  make  up  the 
tumor  carry  before  them  the  peritoneum,  which  forms 
the  hernial  sac.  External  to  it,  are  delicate  invest- 
ments of  connective  tissue  layers,  derived  from  the 
sub-peritoneal  fascia  and  the  septum  crurale.  Sir  Astley 
Cooper  named  the  sub-peritoneal  layer  of  connective 
tissue  the  fascia  propria,  and  describes  it  as  thicker 
than  the  peritoneum,  close  and  firm  in  its  texture,  em- 
bracing the  whole  of  the  tumor  to  its  very  neck;  more 
or  less  adipose  tissue  is  interposed  between  this  layer 
and  the  peritoneal  covering  of  the  tumor.  Although 
these  layers  of  fascia  are  important  and  have  been 
described  by  the  earlier  anatomists  at  great  length, 
they  are  often  so  blended  and  fused,  as  to  defy  dis- 


-  98  - 

tinction.  It  is  well  to  remember  that  the  investment 
of  a  femoral  hernia  should  consist  of  peritoneum, 
fascia  propria,  septum  crurale,  crural  sheath,  cribri- 
form fascia,  adipose  tissue,  and  integument.  All  com- 
bined, usually,  make  a  very  thin  covering  of  the  tumor, 
and  their  dissection  should  be  conducted  with  even 
greater  care  than  in  inguinal  hernia. 

The  contents  of  a  femoral  hernia  are  similar  to 
those  of  inguinal.  Omentum,  however,  is  usually  less 
common  and  is  rarely  found  unassociated  with  a  loop 
of  intestine.  Sir  Astley  Cooper  states,  he  met  with 
omentum,  as  the  only  contents  of  the  sac,  but  twice. 
Mr.  Lawrence. observes  that  he  has  seen  it  more  fre- 
quently. Hesselbach  described  a  case  where  the 
ovary  and  tube  formed  the  contents  of  a  crural  hernia 
of  the  left  side.  Femoral  hernia  is  necessarily  subject 
to  comparatively  few  and  unimportant  variations.  In 
rare  instances,  the  hernial  sac  is  found  on  the  outer 
side  of  the  femoral  vessels  in  front,  or  even  behind 
them. 

The  tumor  usually  descends  vertically,  through 
the  crural  canal,  along  the  inner  compartment  of  the 
sheath  of  the  femoral  vessels,  as  far  as  the  saphenous 
opening.  Here  the  sheath  is  greatly  narrowed  and  in 
close  contact  with  the  vessels;  the  superficial  fascia 
and  crural  sheath  are  closely  attached  to  the  lower 
part  of  the  saphenous  opening,  and,  by  these  obstruc- 
tions, the  tumor  is  prevented  from  extending  lower. 
In  its. farther  progress  it  is  directed  forwards,  carrying 


—  99  — 

before  it  the  cribriform  fascia,  and  curves  upwards  up- 
on the  falciform  process  of  the  fascia  lata  and  lower 
part  of  the  tendon  of  the  external  oblique,  retained 
only  by  the  superficial  fascia  and  integument. 

When  in  the  canal,  owing  to  its  firm,  resisting 
walls,  the  hernial  tumor  is  small,  but  after  escaping 
from  the  saphenous  opening,  it  may  become  of  con- 
siderable size.  "  In  the  female  it  is  generally  very 
movable  and  being  soft,  and  the  skin  not  being  dis- 
colored, it  has  the  appearance  merely  of  an  inguinal 
tumor  of  one  of  the  absorbent  glands;  but  in  the  male, 
the  skin  is  generally  not  so  loose,  the  swelling  not  so. 
distinctly  circumscribed,  and  the  tumor  appears  buried 
more  in  the  substance  of  the  thigh. 

The  largest  size  to  which  I  have  seen  the  tumor 
arrive  was  in  cases  of  which  I  have  given  plates  in 
this  work.  The  one  was  in  the  male,  the  other  in  the 
female;  they  were  each  of  them  about  the  size  of  the 
fist,  and  each  occupied  the  whole  of  the  hollow,  from 
the  anterior  superior  spinous  process  of  the  ilium,  to 
the  tuberosity  of  the  pubis.  But  my  friend,  Mr. 
Thompson,  Professor  of  Military  Surgery  at  Edin- 
burgh, mentions  a  case  of  a  woman,  laboring  under  an 
old  irreducible  crural  hernia,  in  whom  the  tumor  ex- 
tended half  way  down  the  thigh.  In  this  case  the 
parietes  of  the  abdomen  were  so  thin,  that  the  peristal- 
tic motion  of  the  intestine  could  be  distinctly  per- 
ceived. Upon  the  whole,  however,  it  is  unquestion- 
able, that  the  crural  hernia   is   comparatively   smaller 


lOO 


than  the  inguinal,  and,  on  this  account,  it  is  the  more 
dangerous."* 


ElG.    12. 

Femoral  Hernia.— Agnew. 

In  femoral  hernia,  the  location  of  the  stricture 
varies.  It  may  be  found  in  the  neck  of  the  hernial 
sac.  This,  however,  is  rare;  more  commonly,  it  is 
found  at  the  junction  of  the  process  of  the  fascia  lata 
with  the  edge  of  Gimbernat's  ligament,  or  at  the 
margin  of  the  saphenous  opening. 

Usually,  the  division  of  the  stricture  should  be 
made  upwards  and  inwards.  This  is  the  rule,  unless 
the  disposition  of  the  vessels  should  contra-indicate. 

The  edge  of  the  constriction   is  usually  sharply 


Sir  Astley  Cooper,  Opp.  Cit. 


lOI    

defined,  and  its  division,  to  the  extent  of  two  or  three 
lines,  is  generally  sufficient. 

Femoral  hernia  is  recognized  by  the  same  general 
symptoms  as  inguinal  hernia.     When  reducible,  it  dis- 
appears in  the  recumbent  position,  to  return    when 
erect;  it  is  distended  upon  coughing.     Its  mtestmal 
contents  are  elastic  and  uniform  to  the  touch,  and  a 
gurgling  sound  is  heard  when  it  is  returned  mto  the 
abdomen.     The  surface  is  less  equal  and  has  a  doughy 
feel  when  omental.     Femoral  hernia  is  usually  diag- 
nosticated without   much   difficulty,  since  tumors  of 
the  groin  are  much  less  common  than  of  the  scrotum. 
There  are  conditions,  not  infrequently,  however,  where 
the   diagnosis  is  not  easily  determined.      Cases  are 
reported  where  the  intestine  was  divided  under  the 
supposition  that  the  tumor  was  a  suppurating  bubo; 
also    where,  under   a   similar    supposition,    poultices 
were  applied,  and  death  supervened  from  gangrene  of 
the  enclosed  intestine.     An  enlarged  gland  may  also 
complicate  the  conditions,   occurring  in  conjunction 
with  hernia.      Cystic  dilatation  of  a  portion  of  the 
hernial  sac  may  form  a  complication.     I  have  very 
recently  operated  upon  a  woman  of  about  40,  who 
had  suffered  from  femoral  hernia  for  twelve  or  thirteen 
years,  much  of  the  time,  wearing  a  truss.     A  portion 
of  the  tumor  became  irreducible  and  the  truss  could 
not  be  tolerated.     The  sac  was  thick-walled  and  the 
lower   portion   was   occluded   and  filled  with  serum, 
making  a  tumor  the  size  of  a  small  egg. 


Varicosity  of  the  femoral  vein  may  be  mistaken 
for  a  hernia.  Sir  Astley  Cooper  relates  a  case  where 
he  was  consulted  for  a  supposed  hernia:  "  It  was 
easy  to  detect  the  nature  of  the  case,  for,  although  it 
disappeared  in  the  recumbent  position,  it  was  immedi- 
ately reproduced,  although  she  continued  in  that  posi- 
tion, by  pressing  upon  the  vein  above  the  crural  arch, 
and  retarding  the  return  of  the  blood.  She  died  of 
stricture  in  the  colon;  and,  upon  inspecting  the  body, 
I  found  that  1  could  readily  thrust  my  finger  into  the 
crural  vein,  but  that  she  had  no  hernia."  * 

I  have  lately  been  consulted  in  a  case  of  a  limited 
varicose  femoral  vein,  more  than  an  inch  in  diameter, 
where  upon  standing  a  differential  diagnosis  was  not 
easily  made.  I  am  assured,  however,  this  condition  is 
rare.  Psoas  abscess  and  fatty  tumors  should  also  be 
taken  in  consideration  as  possible.  Mistaken  diagno- 
sis, confounding  a  femoral  with  an  inguinal  hernia,  is 
not  so  very  rare.  This  is  of  less  inmportance  in  gen- 
eral practice,  although  intelligent  efforts  at  reduction 
must  depend  upon  a  diagnostic  recognition  of  the 
anatomical  relations,  and  a  femoral  hernia  goes  over 
into  a  dangerous  constriction  of  the  intestine  more 
rapidly  than  the  inguinal.  In  operative  measures,  a 
correct  diagnosis  is  of  the  first  importance.  Fatal 
errors  have  been  made,  otherwise  avoidable. 

Inguinal  and  femoral  hernia  may  be  rarely  found 


*Sir  Asiley  Cooper,  Opp.  cit. 


—   103  — 
occurring  in  the  same  subject.     It  is  more  common 
upon  the  right  than  the  left  side. 

OPERATIVE  MEASURES. 

\ttempt  at  cure  of  femoral  hernia  has  been  far 
less    common    than   of   inguinal   hernia.      Operative 
measurs  have  been  instituted,  in  rare  instances,  except 
to  relieve  intestinal  obstruction.     When  strangulation 
has  occurred,  the  sharp,  unyielding  edge  of  the  ring 
produces  a  much  more  dangerous  constriction  than 
in  inguinal  hernia,  and  calls  for  even  more  prompt 
measures  of  relief.     Cases  are  on  record  where  death 
has  followed   from   strangulation  within  twenty-four 
hours  after  the  accession  of  the  symptoms.     Not  very 
rareW,  forty-eight  to  sixty  hours  compression  o    the 
intestine  will  cause  necrosis.     This  supervenes  all  the 
more  rapidly  in  femoral  hernia,  since  the  size  of  the 
opening  is  small  and  the  edge  of  the  ring  sharp  and 

""'if  reduction  cannot  be  safely  secured  under  ether 
by  taxis,  intelligently  conducted,  the  thigh  somewhat 
flexed  and  adducted,  or  rotated  inwards,  operation 
should  not  be  delayed.  Having  relaxed  the  tissues, 
as  much  as  possible,  in  this  position,  press  gently  di- 
rectly downwards  upon  the  tumor.  Pressure  is  steadily 
to  be  kept  up,  for  some  minutes,  until  the  surface  o 
the  tumor  is  brought  even  with  the  line  of  the  crural 
arch  and  then  the  compression  is  to  be  continued  up- 
wards and  inwards,  towards  the  abdomen.     If,  on  the 


Fir..  13. 

For  description  of  this  cut  see  page  96,  second  paragraph 
ejse^.  under  Fig.  11.  This  description  inserted  under 
tig.  II  by  mistake. 


—  I05  — 
contrary,  the  pressure  is  first  directed  towards  the  ab- 
domen, the  tumor  is  carried  over  the  arch,  instead  of 
under  it,  and  the   greatest  danger   may  ensue   from 
•force  thus  applied. 

The  direction  of  the  incision,  through  the  integu- 
ments, may  be  somewhat  varied,  but  usually  it  should 
be  nearly  vertical,'  and  from  two  to  three  inches  in 
length.  It  should  extend  downwards  upon  the  inner 
side  of  the  neck  of  the  sac,  and  be  continued  upward, 
about  one  inch  above  Poupart's  ligament.  If  the  in- 
cision is  slightly  curved,  the  concavity  should  embrace 
the  neck  of  the  tumor. 

After  the  division  of  the  integuments  and  fascia, 
tisually  a  well-defined,  membranous  sac  comes  into 
view,  and  the  land-marks  to  be  especially  sought,  as 
guides  for  the  safe  manipulation  of  the  sac,  are 
Poupart's  ligament  above  and  in  front,  and  Gimber- 
nat's  ligament,  at  the   pubic  border,   upon  the  inner 

side. 

Expose  clearly  Poupart's  ligament  in  the  dissec- 
tion, and  determine  with  the  finger,  the  edge  of  Gim- 
bernat's  ligament  upon  the  inner  side  of  the  neck  of 
the  sac.  The  more  common  practice  is,  not  to  open 
the  sac,  but  on  the  finger  carry,  with  care,  the  hernia 
knife  between  the  ligament  and  neck  of  the  tumor, 
and  cutting  inwards,  divide  a  few  of  the  fibres  of  the 
ligament.  This  done,  usually,  in  very  recent  cases, 
the  tumor  may  be  reduced  en  mass  without  opening 
the  sac.      The  operation  thus  conducted,  is  generally 


—  jo6  — 

simple  and  safe,  and  may  be  selected  if  only  relief 
from  the  intestinal  obstruction  is  sought.  Even  then^ 
it  must  be  determined  that  the  stricture  has  been 
limited  to  a  few  hours,   and  that   the  intestine   has 


«,  muscular  portion  of  the  crural  arch  occupied  by  the  iliaeus 
internus;  b,  psoos  magnus;  c,  crural  nerve,  with  iliac 
fascia  in  front;  d,  Poupart's  ligament;  e,  lemoral  artery; 
/,  femoral  vein,  with  the  iliac  and  transversalis  fascia 
separating  at  the  inner  edge  of  the  muscles,  g,  and  pass- 
ing in  front  and  behind  the  vessels  to  form  their  sheath, 
with  its  vertical  membranous  partition,  k;  i,  Gimbernot's 
ligament;  j\  femoral  ring. — Agnew. 

escaped  injury  from  taxis.  Should  it  be  preferred  to 
operate  in  this  way,  the  conditions  to  justify  it  would 
be  manifestly  exceptional,  and,  under  the  protection  of 
antiseptic  measures,  little  if  any  additional  danger 
ensues  from  the  major  operation.     I  cannot  doubt  the 


—   I07  — 

wisdom  and  great  advantage  of  adopting,  as  the  rule 
of  practice,  the  opening  of  the  sac  before  any  attempt 
is  made  to  divide  the  stricture.  In  doing  this,  the 
fascia  propria  is  divided  on  a  director,  when  a  layer  of 
fat,  already  referred  to,  is  exposed  to  view.  This  is 
important,  since  it  might  be  mistaken  for  omentum. 
Having  exposed  the  peritoneal  covering  of  the  sac, 
this  should  be  determined  and  opened  with  the  care 
and  caution  already  emphasized,  when  describing  this 
step  of  the  operation  in  inguinal  hernia.  Generally,  a 
little  serum  escapes,  which  farther  determines  the 
anatomical  relations  of  the  parts.  Enlarge  the  open- 
ing sufficient  to  admit  the  finger,  and,  held  in  this 
way,  free  the  sac  from  its  s'.irrounding  attachments. 
Carefully  carry  the  hernia  knife  on  the  finger,  and 
divide  the  constriction,  at  its  mouth,  by  cutting  in- 
wards and  upwards,  as  little  as  required,  to  liberate 
the  intestine.  Then  examine,  and  if  warranted,  re- 
store the  abdominal  contents.  The  next  step  is  to 
free  the  sac  quite  within  the  ring  and  making  it  tense 
sew  through  its  base  evenly,  with  double,  animal 
suture,  as  advised  in  inguinal  hernia.  Cut  the  sac 
away,  and  return  the  sutured  base  within  the  ring. 

Protect  the  femoral  vessels  in  their  sheath  by 
pressing  them  gently  outwards,  and  introduce  the 
needle,  as  directed  in  inguinal  hernia,  from  below, 
through  the  falciform  process  of  the  fascia  lata,  avoid- 
ing the  internal  saphenous  vein,  upwards  through  Pou- 
part's  ligament,  withdrawing  the  opposite  end  of  the 


—  io8  — 

suture  with  the  needle.  A  second  stitch  is  taken  through 
the  same  tissues,  parallel  to  the  first,  about  one-fourth 
of  an  inch  nearer  the  median  line;  the  third  is  intro- 
duced through  the  pubic  portion  of  the  fascia  lata, 
parallel  to  the  saphenous  vein,  and  is  carried  upwards 
to  include  Gimbernat's  ligament,  or  its  divided  fibres, 
if  cut  in  strangulation;  a  fourth,  and  as  many  more 
stitches  as  may  be  required  to  close  the  saphenous 
opening,  is  carried  below  and  parallel  to  Poupart's 
ligament,  through  the  pubic  fascia  and  the  falciform 
fascia.  In  this  way  the  peritoneal  pouch  is  obliterated 
and  the  neck  of  the  sac  firmly  closed. 

The  animal  suture  is  carried  parallel  to  the 
femoral  vein;  the  strong  tendinous  borders  of  Pou- 
part's ligament  and  the  thick,  reinforced  edge  of  the 
fascia  lata,  above  the  saphenous  opening,  are  closely 
approximated  and  firmly  held,  including  the  weakened 
Gimbernat's  ligament.  Thus  the  upper  portion  of  the 
crural  ring  is  closed.  The  lower  part  of  the  canal  is 
obliquely  elongated,  and  reformed  by  drawing  inwards 
the  weakened,  dilated  upper  and  outer  border  of  the 
saphenous  opening  and  attaching  it  to  the  firm  pubic 
fascia.  The  folding  over  of  the  fascia,  in  this  way, 
carries  the  saphenous  opening  quite  a  little  to  the 
inner  side  of  its  former  site,  while  the  femoral  vessels 
are  undisturbed  in  their  sheath.  The  superficial  tissues 
and  skin  are  closely  held  in  conjunction  by  buried 
sutures  and  the  wound  dressed  with  iodoform  collo- 
dion, as  advised  in  inguinal  hernia. 


—   I09  — 

In  many  instances,  the  incision  and  dissection 
will  not  be  required  to  be  made  "as  extensively  as 
above  advised.  Experience  will  familiarize  the  opera- 
tor with  the  anatomical  relations,  but  the  open  wound 
should  enable  him  clearly  to  distinguish  the  vessels 
and  render  certain  the  closure  of  the  parts  involved. 
The  operation  for  the  cure  of  femoral  hernia  is,  with- 
out doubt,  more  difficult  than  in  inguinal.  Properly 
done,  it  is  almost  without  danger,  and  the  wearing  of 
a  truss  in  this  variety  of  hernia  is  much  more  trouble- 
some. I  cannot  doubt  operation  for  its  cure  will  be 
much  more  frequently  resorted  to  than  at  present. 

Dr.  John  Wood,  of  London,  is  world-wide  famous 
for  his  subcutaneous  wire  suture  for  the  cure  of  her- 
nia, and,  although  I  shall  refer  to  his  methods  later, 
when  discusssing  the  various  ways  devised  for  this 
purpose,  I  quote  here  his  operation  for  closure,  after 
herniotomy,  with  the  purpose  of  cure. 

"  When  under  the  spray  the  sac  has  been  opened, 
the  stricture  divided,  the  bowel  and  omentum  drawn 
down  and  examined  carefully,  and  the  former  found 
not  essentially  injured,  with  no  ulceration  at  the 
strangulated  part,  and  no  appearance  of  sphacelus,  the 
operation  should  be  concluded  by  tying  up  the  neck 
of  the  sac  by  strong  catgut,  at  the  level  of  the  crural 
ring,  and  cutting  off  the  sac  just  below.  If  the  sac  be 
large  the  catgut  should  be  made  to  transfix  it,  and 
should  be  tied  tightly  on  either  side.  Then  after 
passing    the    needle  through   Poupart's  ligament   on 


the  one  hand,  and  through  the  pubic  fascia  lata 
and  Gimbernat's  ligament  on  the  other,  as  above  de- 
scribed, the  needle  should  again  be  passed  horizontally- 
through  the  pubic  fascia  lata,  just  below  its  insertion 
into  the  pectineal  line,  and  the  inner  end  of  the  wire 
hooked  on  and  drawn  through.  Then  the  two  ends  of 
the  wire  should  be  twisted  together,  and  the  loop 
drawn  up  and  twisted  firmly  down  into  the  upper  skin 
puncture.  A  drainage-tube  should  next  be  placed  in 
the  lower  part  of  the  wound,  reaching  as  high  as  the 
closed  crural  ring,  and  two  or  three  points  of  suture 
applied.  Upon  the  protective,  a  double  pad  of  wet, 
carbolized  gauze  should  be  placed,  so  arranged  that  a 
groove  is  left  to  lodge  the  end  of  the  drainage-tube, 
and  to  give  free  exit  for  any  discharge. 

Then  the  rest  of  the  antiseptic  dressing  is  to  be 
applied,  with  plenty  of  loose  padding,  especially  on 
the  inner  side,  to  absorb  the  discharge,  and  a  spica 
bandage  above  all.  If  the  discharge  does  not  soak 
through,  the  dressing  may  be  left  for  three  days,  when, 
if  primary  union  has  occurred,  as  is  most  likely,  the 
stitches  may  be  removed  and  the  drainage-tube 
cleansed  and  reapplied,  shortened  by  about  half  an 
inch.  In  another  three  days  the  dressing  should  be 
changed,  and  the  wire  removed,  the  tube,  again  short- 
ened, being  kept  in  until  the  next  dressing  in  three  or 
four  days  more.  The  tube  will  then  generally  require 
removal. 

I    have  operated  for  the  radical  cure  of   crural 


—  Ill   — 

hernia  by  the  wire  operation,  directly  after  the  opera- 
tion of  herniotomy  for  strangulation,  in  four  cases,  all 
in  women.  In  the  first  two  the  spray  was  not  used, 
but  all  the  other  antiseptic  precautions  were  employed. 
In  the  last  two,  the  spray  and  Lister  dressings  were 
used.  All  the  patients  recovered  without  a  bad  symp- 
tom, each  having  a  good,  firm,  resisting  cicatrix;  no 
return  of  the  rupture  has  occurred,  as  far  as  known, 
up  to  the  present  time. 

We  should  no  doubt  be  prepared  to  expect  a 
higher  rate  of  mortality  in  this  operation  than  in 
that  upon  unstrangulated  hernia.  Very  much  will 
depend  upon  the  care  and  judgment  ot  the  surgeon 
as  to  the  condition  of  the  bowel  and  omentum, 
before  venturing  to  return  them  into  the  abdomen, 
and  upon  his  choice  of  cases  in  which  strangu- 
lation is  recent.  With  due  caution  we  may  expect 
confidently  that  no  higher  rate  of  mortality  than  is 
met  with  in  ordinary  crural  herniotomy,  will  be  ex- 
perienced. And  if  so,  it  certainly  seems  to  be  a  short- 
coming in  surgery  not  to  take  advantage  of  the  o^^en 
wound,  to  cure,  if  possible,  the  hernia,  by  the  same 
operation  as  that  which  is  necessary  to  relieve  strangu- 
lation. It  is  well  known  that  by  not  doing  so,  the 
hernia  is  left  to  become  larger  and  more  troublesome 
to  retain,  because  of  the  crural  ring  being  cut  so  as  to 
be  more  open  and  unprotected  than  before  the  opera- 
tion. To  be  successful,  as  a  rule,  cases  must  be 
operated  on  as  soon  as  possible  after  a  fair  trial  of  the 


112    

taxis,  aided  by  inversion  and  anaesthesia,  has  been 
made.  But  this  rule,  also,  operates  favorably  in  an 
operation  which  is  usually  successful  in  saving  the  pa- 
tient in  inverse  proportion  to  the  amount  of  damage 
done,  chances  lost,  and  time  misemployed  by  ill- 
directed  and  unskillful  use  of  the  taxis  or  other  futile 
methods  of  treatment;  and  this  especially  in  thin^ 
feeble,  female  patients  after  the  middle  period  of 
life/'t 


f  Article  on   Hernia.     John  Wood,  International   Cyclo» 
poedia  of  Surgery,  Vol.  V,  p.  1161, 


CHAPTER  VIII. 

OBTURATOR    HERNIA. 

The  obturator  artery  passes  forwards,  below  the 
brim  of  the  pelvis,  to  the  groove  in  the  upper  border 
of  the  obturator  foramen,  and  escapes  through  this 
opening  from  the  pelvic  cavity.  The  oblique  canal 
thus  formed  by  the  horizontal  branch  of  the  pubes 
above  and  the  arched  border  of  the  obturator  below, 
is  rarely  the  site  of  hernia.  It  has  been  described 
under  various  names,  as  obturator,  after  the  canal,  the 
hernia  of  the  foramen  ovale,  the  thyroid  or  sub-pubic 
femoral. 

The  hernial  sac  is  never  wanting,  and  consists 
always  of  a  portion  of  the  parietal  peritoneum,  carried 
before  the  contents  through  the  canal.  The  sac  is 
here  generally  formed  slowly,  because  of  the  firmer 
attachments  of  the  parts,  and  a  careful  history  will 
usually  elicit  symptoms  of  localised  pain,  cramps,  and 
derangement  of  the  functions  of  the  intestinal  canal. 
When  the  canal  is  distended  the  pain  over  the  course 
of  the  obturator  nerve,  from  pressure  upon  it,  is  at 
times  a  very  diagnostic  symptom.  The  canal,  almost 
never,  dilates  to  the  extent  found  in  other  varieties, 
and,  in  the  great  majority  of  cases  reported,  the  con- 
dition was  not  discovered  until  after  death,  since  an 
external  tumor  is  exceptional.  Mr.  Birkett,  who  has 
especially  studied  the  subject,  writes:     "  After  passing 

9   DD 


~  114  — 

along  the  obturator  canal,  the  hernial  tumor  emerges 
upon  the  thigh,  below  the  horizontal  ramus  of  the 
pubes,  to  the  inner  side  of  the  capsule  of  the  hip- 
joint;  behind  and  a  little  to  the  inner  side  of  the 
femoral  artery  and  vein;  and  to  the  outer  side  of  the 
tendon  of  the  adductor  longus.  The  tumor  formed  by 
the  protrusion  is  covered  by  the  pectineus  muscle. 
From  crural  hernia,  therefore,  it  may  be  distinguished 
by  observing  the  relative  positions  of  the  horizontal 
ramus  of  the  pubes  and  of  the  femoral  artery.  These 
structures  occupy,  in  fact,  a  position  between  these 
two  kinds  of  hernia.  In  obturator  hernia,  they  are 
in  front  of  the  tumor;  in  crural  hernia,  they  are  behind 
it.  In  the  former,  then,  they  are  easily  felt;  in  the 
latter  they  cannot  be  without  difficulty — not  perhaps 
until  the  hernia  is  reduced. 

In  those  cases  in  which  either  a  fullness,  slight 
hardness,  tumefaction,  or  swelling  exists,  coupled  with 
well-marked  indications  of  obstruction,  or  strangula- 
tion in  some  part  of  the  alimentary  tube,  the  difficulty 
of  diagnosis  is  not  so  very  great;  but  how  much  em- 
barrassment arises  when  those  symptoms  which  be- 
token strangulated  bowel  exist,  and  a  tumor  is 
nowhere  to  be  felt,  let  the  numerous  cases  on  record 
attest,  in  which  the  rupture  has  only  been  found  after 
death."  * 


*  System     of     Surgery.     Holmes.     Vol.    II,     page    741. 
American  edition. 


—  115  — 

When  the  symptoms  of  intestinal  obstruction 
exist,  a  differential  diagnosis  may  sometimes  be  im- 
possible. Localized  pain,  especially  over  the  distri- 
bution of  the  obturator  nerve  has  already  been  re- 
ferred to.  Movements  of  the  hip  joint  may  be  pain- 
ful, especially  rotation  outwards,  since  this  compresses 
the  canal.  Localized  comparison  and  pressure  over 
the  obturator  foramen  of  each  side  is  important;  also 
a  careful  inspection  of  Scarpa's  triangle  on  each  side. 
The  pelvic  opening  of  the  obturator  canal  can  be  felt 
by  the  finger  in  the  vagina,  or  rectum,  and  the  addi- 
tional evidence  which  such  examination  will  give 
should  never  be  omitted.  Having  detected  a  hernial 
tumor,  the  effort  at  its  reduction  should  be  carefully 
made.  The  pressure  should  be  directed  in  a  manner 
to  free  the  hernia  from  the  ramus  of  the  pubes  and 
carry  it  upward  from  beneath.  To  divide  the  con- 
striction, it  is  necessary  to  make  a  careful,  rather  deep 
dissection  through  the  integuments,  in  a  line  parallel 
to,  and  quite  inside  the  femoral  vessels.  The 
pectineus  muscle  is  divided  and  separated,  and  also 
very  likely  the  fibres  of  the  obturator.  Until  this  is 
done,  the  finger  can  hardly  be  carried  within  the 
canal.  The  stricture  should  be  divided  inwards,  as 
less  likely  to  injure  the  obturator  artery.  Sir  Astley 
Cooper  relates  a  case  operated  upon  by  M.  Arnaud, 
where  a  portion  of  omentum  was  removed,  with  the 
sac,  followed  by  cure,  but  he  criticizes  the  operation 
as  needless  and  states  that  in  a  case  of  strangulation 


—  ii6  — 

where  other  measures  have  failed,  '*  the  operation  of 
cutting  the  ligament  which  embraces  the  sac  is  the 
only  hope  of  preserving  life.  This  operation  must  be 
extremely  difficult,  and  so  far  as  I  am  informed,  it  has 
never  been  performed."  According  to  Lawrence,  the 
elder  Arnaud  is  entitled  to  the  honor  of  having  first 
demonstrated  this  variety  of  hernia.  Duveney  met  it 
post-mortem,  and  communicated  his  observations  to 
the  Royal  Academy  of  Sciences,  but  they  were  not 
printed  in  their  Memoirs. 

In  a  female,  upon  both  sides  of  the  pelvis,  the 
peritoneum  had  been  protruded  through  the  openings 
of  the  obturator  canal  and  formed  tumors,   size  of  an 

They  contained  intestine,  were  placed  between 
the  anterior  heads  of  the  triceps  and  formed  an  ex- 
ternal tumor.  The  first  publication,  in  which  the  ex- 
istence of  an  obturator  hernia  was  clearly  demon- 
strated, was  by  Garengeot. 

In  M.  Cloquet's  work  there  is  described  and 
figured  a  case  of  obturator  entero-epiplocele  which  re- 
sulted in  death. 

Hilton*  reports  a  case  simulating  intestinal  ob- 
struction within  the  abdomen,  to  relieve  which,  gastro- 
tomy  was  performed. 

According  to  Mr.  Birkett,f   the  first   surgeon   to 


*J.  Hilton,  Med.  Chir.  Tr.,  Lond.,  1848,  xxxi,  323-335- 
fOp.  cit. 


—  117  — 
operate,  followed  by  cure,  was  Mr.  Obr^,  of  London, 
in  1 85 1.     Patient  a  tall,  stout  female,  aged  51.     He 
incised  the  sac  and  its  orifice  and  returned  a  congested 
loop  of  intestine. 

The  next  report  which  I  find  was  in  1853,  by  B. 
Cooper.*  Division  was  made  and  contents  returned; 
recovery  slow,  but  satisfactory. 

The  same  year,  operation  and  cure  by  M.  Case.f 

Since  the  above  dates,  I  have  found  reports  of 
twelve  operations  undertaken  for  obturator  hernia,  with 
seven  recoveries. 

I  have  met  this  variety  of  hernia  only  once.  A 
girl  of  twelve  years  was  supposed  not  seriously  ill 
until  three  days  before  death.  She  received  a  severe 
strain  from  sliding  down  the  banister-rail  of  a  stair- 
way. Continued  at  school  the  following  day,  was 
seized  with  symptoms  of  intestinal  obstruction,  ster- 
coraceous  vomiting,  and  was  in  extremis,  when  I  was 
summoned  by  Dr.  M.  D.  Church,  of  Cambridge. 
There  was  an  illy-defined  tender  tumor  upon  the  inner 
side  of  the  thigh,  below  the  pubes,  the  size  of  a  small 
egg.  The  abdomen  was  tense  and  tympanitic.  The 
fact  that  strangulation  had  existed  for  so  long,  caused 
taxis  under  ether  to  be  undertaken  with  more  than 
•  the  usual  care.  Failing  in  this,  and  fearing  the  intes- 
tine  necrosed,    and    possibly  farther   intra-abdominal 


*Med.  Times  and  Gazette,  London,  1853,  N.  S.  vi.,  113. 
fBull.  gen  de  Therap.,  Paris,  1853. 


complication,  I  determined  to  perform  laparotomy. 
I  was  aided  by  Drs.  Church  and  G.  W.  Nash.  By 
careful  manipulation  of  the  intestine,  gentle  pressure 
being  made  upon  the  tumor,  a  loop  of  darkly  con- 
gested, small  intestine  was  withdrawn  and  the  wound 
closed. 

The  recovery  from  ether  was,  unfortunately,  com- 
plicated by  the  vomiting  of  an  enormous  quantity  of 
dark  fluid,  a  quart  or  more.  The  prostration  was  ex- 
traordinary,   and    death    supervened   in   a  few  hours. 

This,  and  one  or  two  other  instances  of  the  grav- 
est character,  have  taught  me  to  feel  that,  in  such 
severe  cases,  a  careful  washing  out  of  the  stomach  be- 
fore operating  is  of  the  first  importance. 

A  most  interesting  case  is  reported  by  Welsch,* 
where  a  portion  of  the  end  of  the  processus  vermi- 
formis  and  a  very  small  part  of  the  urinary  bladder 
were  carried  into  the  sac.  An  abscess  supervened, 
followed  by  death. 

Although  rare,  this  variety  of  hernia  has  been 
here  treated  at  the  greater  length,  since,  in  most  works, 
it  is  scarcely  more  than  alluded  to.  I  have  no  doubt 
it  often  escapes  observation,  and  death  from  obscure 
abdominal  inflammation  is  the  verdict  generally  ren- 
dered. Since  the  great  majority  of  hernial  cases 
must  come  under  the  observation  of  the  general  prac- 
titioner, it  is  well  to  emphasize  the  possibility  of  this 
very  dangerous  variety  of  intestinal  obstruction. 


*Med.  Cor.  Bl.  d.   Wiirtlemb.   artzl.  Ver.  Stuttg.,  1862. 


—   119  — 

ISCHIATIC    HERNIA. 

A  few  cases  of  this  rare  variety  have  been  re- 
corded. The  tumor  cannot  be  discovered  until  of  a 
considerable  size,  since  it  is  covered  by  the  gluteous 
maximus.  Lawrence  wrote  that,  "  it  has  never  been 
diagnosticated  upon  the  living  subject." 

Sir  Astley  Cooper  relates,  at  length,  a  case  dying 
of  intestinal  obstruction,  where  the  autopsy  showed  a 
strangulated  ischiatic  hernia,  and  illustrates  it  with 
two  plates.  Camper  also  records  a  case  where  the 
ovary  was  in  the  sac. 

Should  ever  the  question  of  operative  interference 
be  deemed  advisable,  Sir  Astley  Cooper  recommended 
that  the  safest  direction,  in  which  the  orifice  can  be 
dilated,  will  be  directly  forward. 

The  weakening  of  the  pelvic  floor  in  w^oman, 
from  child-bearing,  is  a  common  cause  of  a  downward 
displacement  of  the  pelvic  contents.  By  the  earlier 
writers,  quite  a  number  of  these  lesions  were  described 
under  different  varieties  of  hernia,  as  pudendal,  vag- 
inal, and  perineal  hernia,  also  hernia  of  the  urinary 
bladder,  as  cystocele.  All  these  displacements  are  im- 
portant and  interesting,  but  come  more  properly  under 
discussion  in  the  consideration  of  the  injuries  and  dis- 
eases of  the  female  organs,  rather  than  in  a  general 
treatise  upon  hernia. 

Mention  has  been  made,  in  a  number  of  instances, 
where  the  urinary  bladder  entered,  in  part,  into  the 
composition  of  the  hernial  tumor.     A  very  rare  variety 


I20    

is  illustrated  by  a  few  well  authenticated  instances, 
where  a  portion  of  the  bladder  had  passed  through 
the  abdominal  ring  into  the  scrotum,  and  slowly  en- 
larged to  extraordinary  size. 

I  have  never  met  with  this  variety  of  hernia,  but 
when  present,  its  diagnosis  would  not  be  difficult,  and 
in  certain  conditions,  operative  interference  would  be 
justifiable  for  its  restoration  and  proper  retention. 

UMBILICAL    HERNIA. 

This  variety  of  hernia  might  have  been  placed  in 
order  after  inguinal,  since  it  is  of  such  frequent  oc- 
currence. I  have,  however,  thought  best  to  discuss 
the  herniae  of  the  pelvic  region,  as  a  group. 

The  connective  tissue  which  closes  the  umbilical 
opening  is  much  thinner  than  the  surrounding  parts, 
and  the  peritoneum  is  very  much  more  closely  adher- 
ent than  at  any  other  portion  of  the  linea  alba. 

The  umbilical  opening,  through  the  tendon,  is 
not  larger  than  a  quill,  and  is  formed,  like  the  aper- 
tures we  have  already  considered,  for  the  escape  of 
vessels.  It  will  be  remembered,  however,  that  these 
vessels  are  extra-peritoneal  in  their  development  and 
course.  The  umbilical  arteries  arise  from  the  internal 
iliac  arteries  by  the  side  of  the  bladder,  and  are  con- 
tinued to  the  navel,  between  the  peritoneum  and  mus- 
cles. The  umbilical  vein,  after  entering  the  ring,  is 
continued  between  the  peritoneum  and  muscles;  this 
forms  the  round  ligament  of  the  liver.     Thus  we  see 


121     

the  peritoneum,  in  normal  development,  is  never  ab- 
sent beneath  the  umbilical  site. 

Umbilical  hernia  is  often  seen  in  infancy  and 
childhood,  but  is  usually  small  and  easily  controlled; 
it  frequently  protrudes  in  a  pointed,  dependent  tumor, 
generally  contains  intestine,  is  easily  returned,  but 
usually  sensitive  upon  pressure.  Derangement  of  the 
digestion  is  frequently  dependent  upon  it. 

In  adults,  the  tumor  is  in  considerable  variety  of 
shape  and  appearance. 

This  is  dependent,  less  upon  the  size  of  the  open- 
ing, than  upon  the  resistence  offered  to  its  extension. 
In  thin  persons,  it  becomes  pendulous,  circumscribed, 
and  often  pyriform,  in  shape.  In  fat  people,  it  often 
extends  upwards,  as  much  as  in  other  directions,  is 
sometimes  flattened,  and  quite  concealed  by  the  thick, 
abdominal  wall. 

The  coverings  of  the  sac  are,  usually,  intimately 
blended,  and  often  distended,  so  as  to  be  extremely 
thin.  Then,  nothing  of  anatomical  factorage  can  be 
determined,  and,  even  the  peritoneum  which  always 
lines  the  sac,  can  scarcely  be  differentiated.  The  sac, 
in  rare  instances,  may  be  double. 

The  contents  of  the  sac  may  be  intestinal,  omental, 
or  both;  in  large  hernia,  usually  intestine  and  omen- 
tum. The  contents  can  be  generally  distinguished 
without  difficulty. 

Women  are  much  more  often  the  subject  of  um- 
bilical hernia  than  men. 


This  is  dependent,  in  the  large  part,  upon  child- 
bearing,  the  distension  of  the  abdomen  by  the  gravid 
uterus,  pains  of  parturition,  ovarian  tumors,  etc. 
Women  who  have  borne  many  children,  producing  a 
loose,  pendulous  abdomen,  and  then  becoming  corpu- 
lent, are  more  liable  to  large  umbilical  hernia  than 
any  other  class.  In  these  instances,  the  omentum  has 
generally  become  thick  and  heavy  from  a  deposition 
of  fat. 

Children  are,  sometimes,  born  with  a  deficiency 
of  the  structures  about  the  umbilicus.  At  one  side  of 
the  cord,  there  may  be  seen  a  considerable  protrusion^ 
with  only  the  peritoneal  covering,  through  which  the 
intestines  may  be  seen.  Rarely,  even  this  may  be 
wanting.  An  illustrative  case  with  photograph  was 
furnished  me  by  Ur.  William  Hogue,  of  Charlestown, 
W.  Va.  The  boy  was  born  with  non-closure  of  the 
abdominal  wall.  The  intestines  passed  through  the 
opening  and  extended  as  far  as  the  pubes.  The 
opening  was  about  two  inches  in  diameter.  The  child 
was,  otherwise,  well  developed.  The  bowels  were 
replaced,  leaving  the  funis  out,  and  the  abdominal 
walls  were  drawn  together  by  adhesive  plaster. 
The  opening  was  permanently  closed,  in  about  six 
weeks. 

In  attempting  the  reduction  of  an  umbilical 
hernia,  the  recti  muscles  must  be  relaxed.  A  knowl- 
edge of  the  character,  contents,  shape,  and  tension  of 
the  tumor  must  direct  as   to   its   manipulation  for  re- 


—  123  — 
duction.  Often  grasping  with  the  hand,  and  directly 
lifting  it  from  the  ring  will  materially  aid  in  its  reduc- 
tion, at  the  same  time,  gently  kneading  the  neck  of  the 
tumor  with  the  other  hand.  Once  reduced,  it  is  im- 
portant to  retain  it  with  a  truss.  Instruments,  in  some 
variety,  are  to  be  found,  but  the  essential  is  compres- 
sion over  the  opening.  This  is  often  made,  easily 
and  effectually,  by  a  firm  bandage  around  the  body, 
with  a  conical-shaped  pad  to  fit  the  depression. 

UmbiHcal  hernia  may  become  irreducible  from 
the  same  causes  which  produce  irreducible  hernia 
elsewhere.  The  most  frequent  is  the  adhesion  of  the 
omentum.  When  irreducible,  the  tumor,  sometimes, 
grows  to  an  enormous  size,  disabling  the  sufferer,  if 
not  endangering  life.  Rarely,  ulceration  of  the  in- 
teguments occurs,  thus  greatly  complicating  the  suf- 
fering. 

Some  years  since,  I  had  under  observation  a 
large  hernia,  where  the  ulceration  was  so  extensive  as 
to  lay  bare,  to  a  considerable  distance,  both  recti 
muscles.  The  abdomen  was  of  very  exceptional 
weight,  and  cure  was  eifected  only  by  support  and 
prolonged  rest  in  the  horizontal  position. 

A  large  cup  or  basin-shaped  pad  may  often  be  of 
value  to  retain  an  irreducible  umbilical  hernia.  When 
this  is  impossible,  because  of  size  or  pendulous  shape 
of  abdomen,  a  support,  as  a  broad  belt,  carried  over 
the  shoulder,  can  be  arranged  to  relieve,  in  part,  the 
weight. 


—    124    — 

Strangulated  umbilical  hernia  is  not  infrequent. 
It  may  not  be  as  urgent  as  in  inguinal  or  crural,  yet 
Sir  Astley  Cooper  narrates  a  case  which  proved  fatal 
within  eighteen  hours.  The  danger,  of  course,  lies  in 
the  close  constriction  of  the  neck  of  the  sac.  Here 
the  opening  through  the  linea  alba  is  a  circumscribed 
ring,  entirely  inelastic  and  firm,  resisting  the  knife  like 
cartilage.  The  intestine  is  often,  in  a  measure,  pro- 
tected by  a  thick  pad  of  omentum.  In  one  instance 
of  a  strangulated  umbilical  hernia,  where  stercora- 
ceous  vomiting  had  continued  for  three  days,  a  pa- 
tient of  Dr.  H.  L.  Chase,  of  Cambridge,  I  freed  a  loop  of 
very  dark  colored  intestine,  slightly  ulcerated  at  its 
mesenteric  attachment,  and  returned.  It  was  sur- 
rounded by  a  mass  of  necrosed  omentum,  double  fist 
size.  This  was  sewed  through  beyond  its  constriction, 
and  excised.  The  entire  sac  was  resected  by  oblique 
incisions,  and  the  walls  united,  followed  by  a  rapid 
and  permanent  cure.  The  intestine  undoubtedly  es- 
caped necrosis  because  of  its  omental  surrounding. 

In  operation,  it  is  usually  safer  to  open  the  sac 
by  direct  incision  in  the  median  line.  This  is  ordin- 
arily easy,  as  the  sac  is  very  thin.  Of  course  care  is 
required  not  to  injure  the  intestine.  Sometimes  the 
sac  is  so  tense  that  the  contents  are  at  once  pushed 
out  and  are  troublesome.  Covered  by  an  aseptic 
towel,  they  are  carried  to  one  side,  and  the  constrict- 
ing ring  is  divided  by  the  knife  on  the  finger.  After 
a  proper  determination  of  condition,  return  the  abdo- 


—     125    — 

minal  contents.  This  done,  I  do  not  for  a  moment, 
hesitate  to  commend,  in  all  cases,  a  complete  resection 
of  sac  and  ring  by  eliptical  incision,  and  close  carefully 
the  abdominal  opening,  as  in  an  ordinary  laparotomy. 
This  I  think  best  accomplished  by  closing,  in  at  least 
three  lines,  with  a  continuous  buried  animal  suture, 
first  the  peritoneum;  and  then  the  subsequent  steps 
can  be  conducted  under  irrigation.  The  second  layer 
should  be  with  large  suture,  taken  deeply  and  widely, 
for  the  better  support.  The  skin  is  also  approximated 
and  the  wound  dressed  with  iodoform  collodion,  as 
recommended  in  inguinal  hernia.  Sometimes,  the 
tension  upon  the  abdominal  wall  is  very  great,  because 
of  contents.  I  have,  in  one  or  two  such  instances, 
carried  silver  wire  interrupted  sutures  quite  outside 
the  coapting  animal  suturing,  to  act  as  a  splint,  hold- 
ing the  structures  at  rest  during  repair. 

The  treatment  of  necrosed  intestine  has  received 
a  new  interest  in  the  light  of  modern  research.  I 
have  four  times  resected  a  portion  of  the  diseased 
bowel  and  closed  the  inverted  edges  by  continuous 
animal  suture  taken  in  a  modified  Lembert  stitch, 
through  double  layers  of  the  peritoneal  coat.  A 
second  row  of  sutures  was  taken  about  one  fourth  of 
an  inch  from  the  first,  both  entirely  encircling  the  in- 
testine; all  proved  fatal.  Subsequent  autopsies,  in 
three  cases,  showed  absence  of  peritonitis  and  a  local 
exudation  enclosing  the  suturing;  death  apparently 
from    exhaustion,    in    large    measure,    antecedent    to 


126    

operation.  In  one  case,  seen  with  Dr.  H.  C.  White, 
of  Somerville,  the  umbiHcal  tumor  was  size  of  baby's 
head  and  already  necrosed.  We  resected  seven  inches  of 
small  intestine,  together  with  large  masses  of  gangren- 
ous omentum.  Death  supervened  in  sixty  hours.  No 
hemorrhage  or  peritonitis.  The  intestine,  at  point  of 
juncture,  held  water  after  removal  from  the  body. 

To  Dr.  H.  R.  Storer,*  of  Newport,  R.  I.,  formerly 
of  Boston,  is  due  the  credit  of  having  first,  in  America, 
deliberately  undertaken  the  cure  of  umbilical  hernia. 
This  was  in  1866,  and  was  followed  by  primary  union. 

Before  the  days  of  the  proper  understanding  of 
the  active  ferments,  as  factors  in  the  surgical  problem 
of  wound  treatment,  emphasised  by  the  most  serious 
results,  whenever  their  incubation  occurred  within  the 
abdominal  cavity,  we  may  well  understand  the  fear 
and  trembling  associated  with  the  name  of  peritonitis. 
The  experience  of  the  centuries  had  taught  it  to  be 
the  "  noli  me  tangere "  of  surgery.  Upon  this,  in 
large  share,  is  yet  based  the  general  belief  of  the 
medical  profession,  to  defer  operative  measures  as  a 
last  resort.  This  has  been  emphasized,  in  a  much 
greater  degree,  in  the  consideration  of  operative 
measures  undertaken  for  the  cure  of  umbilical,  than  of 
inguinal  hernia.  The  time  is  not  far  distant  when 
the  cure  of  this  often-times  disabling  and  dangerous 
condition  will  be  considered,  as  safe   and    simple,  as 


*N.  Y.  Med.  Record,  1866-67,  p.  73-76. 


—    127    — 

an    exploratory    laparotomy,  and    under   proper  con- 
ditions almost  entirely  devoid  of  danger. 

Diaphragmatic  and  ventral  hernia,  as  also  the 
various  herniae,  which  cause  intestinal  obstruction, 
occurring  within  the  abdominal  cavity,  are  omitted 
from  discussion  as  not  within  the  scope  of  this  work. 
Abdominal  surgery,  however,  has,  at  the  present,  in- 
vested these  conditions  with  an  interest  and  profit 
never  before  associated  with  these  pathological  factors, 
and  very  many  lives  will  be  saved  in  the  future,  where 
even  now,  no  hope  is  entertained.  Every  physician, 
as  well  as  surgeon,  should  familiarize  himself  with  all 
the  conditions  of  impaired  intestinal  function  which 
may  indicate  obstruction  in  its  earlier  stages,  and  be 
able  to  profit  thereby,  either  by  a  wise  interference  on 
his  own  part,  or  calling  to  his  aid  the  more  experienced. 


CHAPTER  IX. 

THE  RADICAL  CURE  OF  HERNIA. 

Few  chapters  m  the  history  of  surgery  are  of 
greater  interest  to  the  student  than  those  in  which  are 
recorded  the  efforts  made  during  the  centuries  for  the 
cure  of  hernia. 

In  the  earUer  writings,  a  very  great  variety  of 
external  applications  were  advised  These  were,  for 
the  most  part,  inocuous,  often  consisted  of  pads 
variously  constructed  of  supposed  medicated  materials, 
and  were  of  value  as  supports.  When  applied  to 
the  young,  they  often  aided  in  cure,  and  were,  on 
this  account,  commended  as  of  value.  Vesication 
was  also  resorted  to.  The  cure  by  cautery  was  known 
to  the  Arabians,  and  is  mentioned  by  Avicenna,  Albu- 
casis,  Paulus  ^gineta,  Fab.  ab.  Aqua  pendente,  and 
others.  The  method  employed  was,  after  the  patient's 
intestinal  canal  had  been  emptied  by  fasting  and 
purging,  to  cauterize  the  projection  of  the  tumor,  pre- 
viously marked  in  ink,  for  which  instruments,  in 
variety  of  shape,  had  been  devised.  Nearly  all  its 
advocates  agreed  that  the  result  must  effect  an  ex- 
foliation of  the  OS  pubis,  the  patient  must  be  restrained 
upon  a  low  diet,  and  retained  in  bed  for  a  very  con- 
siderable period.  A  support  must  be  afterwards  worn, 
since  the  hernia  easily  returned. 

The   caustic  treatment  appeared  to  succeed  the 


—    129    — 

cautery  and  to  have  been  advocated  for  similar  rea- 
sons. An  eschar,  about  one  inch  in  diameter,  was  to 
be  made  over  the  external  ring,  and  by  repeated  ap- 
plications, to  destroy  the  tissues,  including  as  much 
of  the  sac  as  could  be  safely  done  without  injury  to 
the  cord.  The  object  to  be  attained  was  a  cicatrix 
firmly  closing  the  ring.  This  procedure  was  in  use 
for  a  considerable  period,  and  was  advocated  by 
Guido,  Severinus,  Lanfranc,  Parey,  Scultetus  and 
others.  Many  dangerous  complications  and  unsatis- 
factory results  are  recorded  by  these  writers. 

The  danger,  the  suffering,  the  frequent  return  of 
of  the  hernia  behind  the  cicatrix,  compelling  the  use 
of  bandages,  caused  these  measures  gradually  to  fall 
into  disuse. 

As  improvements  upon  the  above  methods,  fol- 
lowed the  punctwn  am'eui?i,  the  royal  stitch^  and  castra- 
tion. Since  the  two  former  were  attempts  in  the 
direction  towards  which  the  pendulum  of  modern 
opinion  has  again  swung,  I  quote  from  the  ever  inter- 
esting work  of  Percival  Pott,  a  surgeon  famous  for  all 
time:  "The  punctnm  aureum  was  performed  as  fol- 
lows: The  bowel  being  emptied  by  purging,  and  the 
hernia  reduced,  an  incision  was  made  through  the  skin 
and  membrana  adiposa,  down  to  the  spermatic  pro- 
cess. This  incision  was  to  be  of  such  length,  as  to 
permit  the  operator,  either  with  his  finger,  or  a  hook, 
to  take  up  the  said  process,  and  to  pass  a  golden  wire 
under  it;  which  wire  was  to  be  twisted  in  such  a  man- 


—  I30  — 
ner  as  to  prevent  the  intestine  from  slipping  down 
again  into  the  hernial  sac,  but  not  so  tight  as  to  inter- 
cept or  obstruct  the  circulation  of  the  blood  to  the 
testicle.  Some  operators  preferred  a  leaden  wire  to  a 
golden  one,  and  others  used  a  silken  ligature.  *  *  * 
The  royal  stitch  was  performed  in  this  manner:  the 
intestines  being  emptied,  and  the  portion  which  had 
descended  being  replaced,  an  incision  was  made  in 
such  a  manner,as  to  lay  bare  the  spermatic  cord,  about 
two  inches  in  length  from  the  abdominal  opening 
downward.  When  the  process  was  freed  from  the 
cellular  membrane,  it  was  to  be  held  up  by  an  assist- 
ant, while  the  surgeon  with  a  needle  and  ligature 
made  a  continuous  suture,  from  the  lower  part  of  the 
incision  to  the  upper,  in  such  a  manner  as  to  unite  the 
divided  lips  of  the  wound  again,  comprehending  the 
cellular  membrane,  and  thereby  endeavoring  to 
straighten  the  passage,  as  they  called  it,  from  the 
belly  into  the  scrotum,  .without  injuring  the  spermatic 
vessels.  The  operation  is  described  by  many  of  the 
old  writers,  with  some  small  variation  from  each  other, 
both  in  the  manner  and  in  the  instruments;  but  all 
tending  to  the  same  end  and  all  proving  that  their 
idea  of  the  disease  and  of  the  parts  effected  by  it, 
were  erroneous  and  imperfect." 

This  operation  was  modified  by  some  surgeons, 
and  not  infrequently  is  resorted  to,  even  at  present,  in 
the  treatment  of  the  wound,  after  strangulation  has 
been  relieved,  by  treating  it  as  an  open  wound.     The 


—  i3f   — 
result,  even  in  practical  hands,  gave,  not  infrequently, 
abscess  of  the  scrotum  and  destruction  of  the  testicle, 
while  the  cord  remaining,  prevented  the  closure  of  the 
ring. 

Although  called  the  royal  stitch,  since  by  its  use 
it  was  hoped  the  testicle  might  escape,  and  by  physio- 
logical process,  subjects  for  the  king  result,  it  became 
evident  that  the  cure  would  be  much  more  satisfac- 
tory by  the  removal  of  the  testicle  and  complete 
closure  of  the  canal. 

In  ecclesiastics  there  seemed  to  be  no  special  ob- 
jection to  the  removal  of  the  testes  and  the  practice 
gradually  grew  to  be  common,  until  by  a  report  pre- 
sented to  the  Royal  Society  of  Medicine,  in  1779,  it 
appears  that  the  Intendent  of  the  Police  of  Paris  had 
observed  that  many  individuals,  who  came  under  his 
inspection,  previous  to  entering  the  military  service, 
had  been  deprived  of  one  or  both  testicles,  in  opera- 
tions for  the  cure  of  hernia.  The  Bishop  of  St. 
Papaul  found,  "that  more  than  five  hundred  children 
had  been  castrated  in  his  diocese,  and  more  than  two 
hundred  had  been  mutilated  at  Breslaw."*  The  in- 
ference is  clear,  although  in  the  hands  of  the  ignorant 
and  designing,  the  operation  was  often  needlessly  per- 
formed; that  the  removal  of  the  sac  and  cord  gave  the 
opportunity  of  making,  in  this  way,  a  firm  closure  of 
the  ring  which  resulted  in  a  permanent  cure.     Such, 


*  Lawrence  on  Ruptures,   page  102. 


~  132  — 

however,  became  the  frequency  and  abuse  of  this 
method,  that  it  was  interdicted  by  law. 

The  distinguished  Prussian  surgeon,  Schumucker, 
dissected  away  the  sac  and  opened  it  to  be  sure  that 
it  was  empty,  and  then  ligaturing  as  closely  as  pos- 
sible to  the  ring,  cut  it  away.  This  he  did  in  two 
cases.  The  elder  Langenbeck  carried  the  results  of 
his  investigations  to  such  legitimate  end  that  I  quote 
the  translation,  as  given  by  Lawrence:* 

"  I  divide  the  integuments  over  the  swelling, 
without  pinching  them  up  into  a  fold,  clear  the  hernial 
sac,  push  back  the  prolapsed  parts,  and  place  a  liga- 
ture on  the  neck  of  the  sac  close  to  the  ring.  The 
tightening  of  this  ligature  gives  no  pain.  If  the  sac 
has  been  completely  detached  from  all  its  connections 
below  the  ligature,  it  perishes.  If,  on  the  contrary,  it 
has  been  separated  only  sufficiently  for  passing  the 
ligature,  and  still  remains  connected  to  the  scrotum 
below,  it  becomes  inflamed  and  the  scrotum  itself  is 
affected  with  inflammatory  enlargement,  as  after  the 
radical  operation  for  hydrocele.  The  detachment  of 
the  ligature  occurs  from  the  ninth  to  the  fourteenth 
day.  If  the  case  is  an  external  inguinal  hernia,  the 
sac  must  be  separated  from  the  spermatic  cord.  I  de- 
tach it  just  below  the  ring,  to  a  sufficient  extent  to  al- 
low the  application  of  the  ligature,  and  leave  the  rest 
undisturbed  in  its  situation.     To  separate  the  entire 


*Bibliotheck  fiir  de  Chirurgie,  B.  ii,  i{ 


—  133  — 

sac  from  the  scrotum  and  from  the  tunica  vaginalis 
propria  testis  would  cause  much  irritation.  The 
operation  is  much  easier  with  small  ruptures,  which 
have  not  descended  into  the  scrotum,  and  in  internal 
inguinal  hernia,  where  the  spermatic  cord,  with  its 
tunica  vaginalis  communis,  lying  on  the  other  side  of 
the  swelling,  is  not  so  closely  connected  to  the  sac.  It 
is  most  easy  m  femoral  herniae  where  the  entire  sac 
can  be  readily  cleared.  I  have  already  performed 
this  operation  twelve  times  with  the  most  successful 
results,  and  all  the  patients  are  capable  of  the  hardest 
labor  without  wearing  a  truss.  Two  years  have 
elapsed  since  I  first  put  my  method  in  practice  on  a 
youth  of  sixteen  with  a  large  scrotal  hernia,  in  whom 
there  is  at  present  no  appearance  of  a  new  protrusion. 
A  year  ago  I  operated  on  a  crural  hernia  in  a  female 
domestic,  who  does  the  hardest  work  without  having 
experienced  any  return  of  her  complaint.  The  liga- 
ture causes  adhesive  inflammation  of  the  serous  sur- 
faces and  the  neck  of  the  sac  becomes  closed  up  to 
the  abdomen  like  the  portion  of  an  artery  which  has 
been  tied."* 

Lawrence,  in  commenting  upon  the  operation, 
although  he  places  great  emphasis  upon  the  import- 
ance of  the  sac  as  a  factorage  of  hernia,  states:  "  But 
in  truth  something  more  is  required;  we  want  a 
remedy  that  should  contract  the  tendinous  opening; 
for  while  that  remains  preternaturally  large,  a  new 
protrusion  is  a  highly  probable  occurrance."* 

*0p.  cit.,  p.  103. 


—  134  — 

This  operation,  however,  found  advocates. 
Arnaud,  Sharp,  Acrel,  Petit,  Abernethy,  and  others 
reported  their  experiences,  but,  while  a  considerable 
number  of  cures  followed,  several  were  dangerously  ill^ 
and  a  few  cases  resulted  fatally.  To  combat  the  in- 
flammations, as  then  understood,  it  is  painful  to  note 
the  bleedings,  purgings,  etc.,  undertaken  for  relief. 
Surgical  operations,  by  what  might  be  called  the  open 
method,  for  the  cure  of  hernia,  slowly  fell  into  dis- 
regard only  to  be  revived  in  our  own  time. 

At  least  they  fell  into  disrepute  with  the  Faculty 
and  were  relegated  to  the  hands  of  the  peripatetic 
pretender  who,  for  a  long  time,  reaped  a  rich  reward 
by  cultivating  this  abandoned  field  of  surgery,  so 
strong  was  the  desire  of  the  suffering  to  obtain  relief 
by  any  means  promising  cure. 

During  this  period,  we  may  trace  a  legitimate 
effort  of  the  surgical  profession,  to  profit  by  the  mon- 
umental labors  of  Cooper,  Camper,  Cloquet,  and 
Scarpa,  and  effect  a  cure  of  this  distressing  complaint. 
Their  teachings,  however,  fell  upon,  a  barren  soil 
in  the  subsequent  generation,  save  in  the  hands  of 
a  few  of  the  leading  surgeons  in  general  hospitals, 
where  late  operations  were  performed  for  the  relief  of 
strangulation,  but  were  often  fruitless  because  of  delay, 
thus  bringing  these  measures  even  into  disrepute. 

The  teachings  of  the  great  master,  Sir  Astley 
Cooper,  found  a  worthy  American  exponent  in  Dr. 
John  Collins  Warren,  of  Boston.    Writing  home  to  his 


—  135  — 

father  July  9th,  1800,  from  London,  then  only  tweuty- 
two  years  old,  he  states:  "  Mr.  William  Cooper,  my 
old  master,  is  succeeded  by  his  nephew  Mr.  Astley 
Cooper,  as  lecturer;  a  young  man  of  the  greatest 
natural  abilities,  and  almost  adored  at  the  hospitals. 
His  practice  is  directly  the  reverse  of  his  Uncle's. 
Old  Mr.  Cooper  would  say:  "  I>et  nature  alone;  she 
will  open  that  abscess  infinitely  better  than  you  can." 
The  other  says:  "  Had  you  dilated  that  abscess  from 
top  to  bottom  at  first,  it  would  have  been  well  long 
ago." 

The  obligations  that  I  am  under  to  Mr.  Cooper 
are  infinite.  He  has  always  treated  me  with  the  most 
particular  attention,  and  suffered  no  opportunity  of 
instructing  me  to  pass  by.  I  wish  it  were  possible 
to  return,  in  the  smallest  degree,  the  favors  with 
which  he  has  loaded  me."* 

In  the  Warren  Anatomical  Museum,  No.  2364, 
there  is  still  preserved  a  portion  of  omentum  4^ 
inches  in  length  removed  from  a  crural  hernia  where 
the  strangulation  had  already  existed  seven  days. 
Dr.  Warren  was  then  but  twenty-seven  years  of  age. 
Of  his  experience  he  writes: 

*'  When  I  began  to  operate  in  Boston,  many  of 
the  great  and  difficult  operations  had  never  been 
performed.  My  father  had  done  a  great  number 
of  amputations  and  extirpations,  and  had  successfully 


*  Life  of  J.  C.  Warren,  vol.  i,  p.  37. 


-   136  - 

removed  many  cataracts.  He  had  also  repeatedly- 
done  the  operation  of  lithotomy;  that  is,  he  did  it, 
four  or  five  times  altogether.  I  have  done  it  since 
then,  including  operations  of  lithotrity,  thirty  to  forty 
times.  But  the  operation  for  strangulated  hernia, 
that  of  aneurism,  and  many  others,  had  not 
been  done  in  Boston.  The  first  cases  of  hernia 
which  I  proposed  to  operate  on  excited  great  op- 
position on  the  part  of  friends  of  the  patient,  and 
surrounding  physicians.  In  consequence  of  this  diffi- 
culty, I  lost  two  or  three  patients  in  the  outset,  from 
delay,  one,  an  only  son  of  the  Rev.  D.  Baldwin;  the 
other,  an  only  son  of  B.  B.  Esq.  In  consequence 
of  these  occurrences,  I  determined  to  operate  soon, 
or  not  at  all.  This  became  known  to  physicians, 
and  they  fell  into  the  plan  of  operating  early.  Since 
this  arrangement,  I  have  lost  scarcely  any  patients  in 
operations  for  strangulated  hernia.  In  the  winter  of 
1805,  I  was  summoned  to  the  wife  of  Dr.  C,  of 
Amherst,  N.  H.,  and  accompanied  by  Dr.  Gorham, 
rode  in  an  open  vehicle  on  the  snow,  the  best  part 
of  a  cold  night  in  February,  to  Amherst.  The  dis- 
ease had  lasted  seven  days.  The  hernia  was  crural 
and  large.  The  intestines  adhered  to  the  peritoneum; 
and  I  dissected  the  peritoneum  from  the  intestine 
through  a  large  space;  cut  off  a  considerable  portion 
of  swelled  omentum,  which  could  not  be  reduced, 
and  which  is  still  to  be  seen  at  the  Medical  College; 
and  reduced  the    adherent    intestine.       The    patient 


—  137  — 
recovered  and  lived  many  years  afterwards.  The 
operation  of  strangulated  hernia  became  at  last  so 
familiar,  that  it  cost  me  no  more  anxiety  than  the  ex- 
tirpation of  a  tumor  especially  since  the  introduction 
of  ether."* 

For  many  years,  I  find  no  record  of  any  attempt 
at  revival  of  methods  of  cure.  In  1828  Dr.  Jameson,t 
of  Baltimore,  reported  a  case  of  cure  following  the 
dissection  and  implantation  of  a  tongue  of  tissue  into 
the  crural  canal.  After  plugging  the  canal,  skin 
flaps  were  united  over  it,  thus  making  a  plastic  opera- 
tion covering  the  parts. 

P.  N.  Gerdy  published  his  method  in  1835.  This 
consisted  of  inflamming,  by  the  application  of  am- 
monia, a  portion  of  the  skin  of  the  scrotum  and  in- 
vaginating  it  within  the  ring  and  retaining  it  by  suture 
through  the  ring.  This  operation  was  variously  modi- 
fied, the  most  interesting  of  which  was  the  device  of 
Belmas,]:  invaginating  the  ring  with  an  inflated  bag  of 
gold  beater's  skin.  The  hernia  was  first  returned,  the 
sac  exposed,  and  the  empty  bag  carried  as  far  as  pos- 
sible towards  the  neck  or  ring. 

A  canula  fixed  in  the  bag  was  then  used  to  inflate 
it,  where  it  was  retained  in  the  sac.    Afterwards  pieces 


*  Life  of  J.  C.  Warren,  vol.  ii,  p.  90. 
f  American  Medical  Recorder,  Vol.  II,  p.  128. 
X  De  la  radicale  des  Hernies,    Rev.  med.  franc,  el  etrong, 
Paris,  1838. 


-  138  - 

of  gold  beater's  skin  were  used,  instead  of  the  inflated 
bag.  A  number  of  cures  resulted.  The  chief  interest 
pertaining  to  this  operation  lies  in  the  experiments 
which  led  to  its  adoption,  since  M.  Belmas  determined 
that  these  tissues,  when  placed  into  the  serous  cavities 
of  animals,  became  adherent  and  organized  as  a  solid 
substance.  These  experiments  are  the  legitimate  an- 
tecedents of  animal  sutures,  and  might  easily  have  led 
up  to  the  incorporation  of  tendon  or  cat-gut  thus  ap- 
plied for  the  closure  of  the  ring.  M.  A.  Bonnet,*  of 
Lyon,  published  his  method  of  the  introduction  of 
three  or  four  pins  through  the  integuments  of  the  sac 
and  the  twisting  of  the  point  so  as  to  compress  the  in- 
cluded parts — a  sort  of  hare-lip  pin.  The  wood  pad 
was  employed  by  accident  by  a  laborer,  with  the  result 
of  cure.  The  pad  was  variously  modified  and  called  the 
Stagner  truss.  From  the  report  of  a  committee  ap- 
pointed by  the  Philadelphia  Medical  Society  in  1835^ 
we  quote:  "An  irritation  of  the  skin  and  subcutaneous 
cellular  tissue  is  produced  by  the  pressure  of  the  hard^ 
unyielding  and  rugose  block,  and  is  gradually  ex- 
tended to  the  tendons  beneath,  as  well  as  to  the  ser- 
ous membranes  of  the  sac,  which  is  closed  and  ob- 
literated at  its  neck,  the  whole  mass  of  integument, 
tendon,  cellular  tissue,  and  the  sac  being  agglutinated 
by  the  process  of  adhesion,  in  such  a  manner,  as  to 
oppose  an  insuperable  barrier  against  the  exit  of  the 


*  Bulletin  general  de  Therapeutique,   May,  1836. 


—  139  — 
intestine."  Later,  the  pads  were  made  smooth.  I 
have  seen  excellent  results  from  their  use,  and  in  one 
case  followed  by  cure,  in  a  young  student,  the  pad 
was  worn  for  a  time  under  so  firm  a  spring  that  it  was 
nearly  imbedded  in  the  swollen  parts.  Only  within  a 
few  days  has  a  man  presented  himself  wearing  a  truss 
with  a  thick  wood  pad  of  his  own  construction,  which 
he  stated  "held  him  when  all  others  had  failed."  It 
is  probable  such  pads  worn  by  the  young  would,  in 
many  cases,  be  followed  by  cure. 

Wutzer,*  of  Bonn,  improved  upon  Gerdy's  method 
of  invagination,  by  the  invention  of  an  instrument 
through  which  was  carried  the  needle.  Both  were 
allowed  to  remain  in  situ  for  eight  or  ten  days.  A 
truss  was  recommended  for  some  months  subsequent. 
Permanent  cure,  however,  seemed  the  exception. 

RADICAL    CURE    BY    THE  USE    OF    THE    SETON. 

The  use  of  the  seton  may  be  traced  far  back  in 
the  history  of  surgery,  and  when  the  inflammatory 
processes  which  supervene  upon  its  use  are  taken  into 
consideration,  it  is  easy  to  conceive  its  supposed 
adaptability  for  the  cure  of  hernia.  The  seton  was 
introduced  into  the  hernial  sac  for  this  purpose  as  a 
recognized  measure  early  in  the  present  century.  No 
definite  results  are  reported,  and  the  practice  has  for 


*Wutzer,   C.  W.  Weber.      Radicale  Heilung  beweglicher 
Leistenbruche,  Bonn,  1840. 


—  140  — 

a  long  time  been  generally  abandoned.  Dr.  Holt- 
house,*  however,  has  given  such  an  exceptionally- 
interesting  statement  of  its  use,  that  I  quote  the  fol- 
lowing: 

"  Cases  are  sometimes  met  with  in  which,  owing 
to  the  smallness  of  the  inguinal  canal,  the  finger  can- 
not satisfactorily  make  out  the  structures  involved  in 
the  operations  which  I  shall  have  presently  to  speak 
of,  and,  under  such  circumstances,  their  performance 
cannot  be  altogether  free  from  risk.  For  these  the 
seton  operation  may  be  performed,  and  from  my  ex- 
perience of  it,  derived,  however,  from  a  limited  num- 
ber of  cases,  I  am  disposed  to  regard  it  with  more 
favor  than  is  usually  accorded  to  it.  True,  I  have 
not  done  it  of  late  years,  but  that  is  because  I  have 
met  with  scarcely  any  cases  that  were  not  amenable  to 
the  superior  operation  by  the  rectangular  pins,  which 
act  both  on  the  sac  and  on  the  canal.  The  following, 
however,  is  an  example  of  the  seton  operation: 

G.  E.,  set.  17,  was  admitted  into  the  Westminister 
Hospital  for  an  oblique  inguinal  hernia,  which  had 
descended  into  the  upper  part  of  the  scrotum,  and 
existed  three  months.  It  was  easily  reduced,  and  no 
truss  had  been  worn  for  it.  On  the  31st  of  July,  i860, 
the  bowels  having  been   previously  cleared  by  castor 


*  On  Hernial  and  other  Tumors  of  the  Groin  and  its 
Neighborhood,  with  practical  remarks  on  the  Radical  Cure  of 
Hernia,  by  Carsten  Holthouse,  London,  1870. 


—    141    — 

oil,  a  seton  composed  of  eight  threads  of  silk  was 
drawn  through  the  inguinal  canal,  the  patient  was  put 
on  low  diet,  and  a  grain  of  opium  given  at  bed-time. 

August  8th.  Seton  removed,  very  little  pain  or 
suppuration  having  been  caused  by  it.  Has  not  had 
any  unfavorable  symptom,  and  looks  and  feels  per- 
fectly well.  Middle  diet,  with  half  a  pint  of  porter, 
was  ordered,  and  a  truss  with  a  weak  spring  was  ap- 
plied. 

Aug.  lo. — Continues  well;  some  tenderness  is 
felt  on  pressure  over  the  inguinal  canal,  and  the  truss 
causes  aching  of  the  part;  it  was  therefore  removed, 
with  an  injunction  to  the  patient  to  place  his  hand 
over  the  site  of  the  internal  ring  during  defecation  or 
straining. 

Aug.  2  1. — Discharged  cured,  but  wearing  a  weak 
truss.     Wounds  very  nearly  but  not  quite  healed. 

Sept.  I. — Presented  himself  at  the  hospital,  the 
wounds  being  now  quite  healed.  The  truss  was  taken 
away. 

Oct.  13. — Continues  very  well,  and  has  gained 
flesh.  He  is  working  as  a  bricklayer's  laborer,  with- 
out a  truss. 

August  31,  1 86 1. — A  month  ago,  or  exactly  one 
year  after  the  performance  of  the  operation,  the  rup- 
ture suddenly  came  down  again,  while  he  was  making 
a  violent  muscular  effort.  He  has  been  nearly  con- 
stantly at  work,  without  a  truss  ever  since  his  discharge 
from  the  hospital. 


142    

Notwithstanding  the  hernia  eventually  returned 
in  this  case,  the  operation  can  scarcely  be  called  an 
unsuccessful  one.  Indeed  it  appears  extremely  prob- 
able, that  had  the  patient  delayed  going  to  work  a 
little  longer,  or  had  he  been  in  a  station  of  life  which 
called  for  less  bodily  exertion,  there  would  have  been 
a  pronounced  success.  This  view  is  supported,  not 
only  by  the  cures  resulting  from  the  use  of  a  truss 
only,  and  to  which  allusion  has  already  been  made, 
but  by  the  following  dissection  of  a  case  in  which  this 
principle  of  operating  was  adopted. 

A  German,  47  years  of  age,  affected  with  a 
scrotal  hernia  of  the  right  side,  was  operated  on  by 
Prof.  Carnochan,  after  Rigg's  method,  on  the  2nd 
of  May,  1857;  the  operation  was  completely  success- 
ful; towards  the  latter  part  of  July,  pulmonic  symp- 
toms made  their  appearance,  and  on  the  9th  of  Sep- 
tember, he  died  of  tuberculosis  of  the  lungs. 

Post-mortem,  loth  of  Sept. — Upon  opening  the 
cavity  of  the  peritoneum,  the  orifice  to  the  hernial  sac 
could  not  be  traced,  the  internal  ring  being  firmly 
closed  around  the  cord.  On  the  outer  side  of  the 
peritoneum,  and'just  below  the  situation  of  the  inter- 
nal ring,  was  found  a  small  rounded  body  of  a  yellow- 
ish color,  supposed  to  have  been  the  remains  of  the 
hernial  sac.  The  upper  portion  of  the  inguinal  canal, 
for  nearly  an  inch,  was  closed  by  plastic  exudation, 
which  had  become  organized  and  somewhat  fibrinous 
in  its  appearance;  while  the  canal  at  its  lower  part 


—  143  — 
and  the  external  ring  were,  to  appearance,  in  their 
normal  condition,  though  the  cord  throughout  the  en- 
tire length  of  the  canal  seemed  to  be  imbedded  in 
plastic  formation.  The  skein  of  silk  used  in  this  case 
being  too  large  for  the  puncture  made  by  the  instru- 
ment, it  was  not  introduced  more  than  one  mch,  which 
will  explain  the  facts  mentioned  of  the  lower  portion 
of  the  canal  and  external  ring  being  in  their  normal 
condition;  while  at  its  upper  portion,  both  the  canal 
and  internal  ring  were  firmly  closed.  In  explanation, 
it  should  be  mentioned  that  Riggs'  operation  is  identi- 
cal in  principle  with  the  seton  operation,  sponge  being 
substituted  for  the  silk  used  in  the  latter.  The  mode 
in  which  to  perform  the  seton  operation  is  the  follow- 
ing: "A  fold  of  scrotum  is  carried  up  on  the  finger 
as  high  into  the  inguinal  canal  as  possible;  a  strong 
curved  needle  set  in  a  handle,  and  having  a  large  eye 
near  its  extremity,  is  next  passed  along  the  palmar 
aspect  of  the  finger,  thrust  through  the  anterior  wall 
of  the  canal,  and  brought  out  on  the  surface,  about 
half  an  inch  or  more  above  the  centre  of  Poupart's 
ligament;  it  is  then  threaded  with  the  number  of 
threads  previously  determined  on,  and  medicated  or 
not,  as  the  case  may  be,  and  withdrawn  through  the 
same  opening  at  which  it  was  entered.  The  upper 
and  lower  ends  of  the  threads  are  tied  together,  and 
pressure  made  over  the  outside  of  the  canal  with  a 
compress  and  bandage.  The  threads  are  allowed  to 
remain  in  the  canal  till  a  sufficient  amount  of  inflam- 


—   144  — 
mation  appears  to  have  been  excited,   and  are  then 
withdrawn   at   periods   varying   from    three   to    nine 
days." 

M.  Velpeau  operated  a  number  of  times  by  open- 
ing the  neck  of  the  hernial  sac  and  introducing  the 
tincture  of  iodine. 

The  success  which  so  often  followed  the  opera- 
tion for  hydrocele  by  injection  led  him  to  adopt  its 
use  for  the  cure  of  hernia. 

An  assistant  compressed  the  inguinal  canal,  so  as 
to  prevent  the  fluid  entering  the  abdominal  cavity.  A 
mixture  of  six  drachms  of  tincture  of  iodine  in  three 
ounces  of  water  was  introduced,  and  after  pressing  it 
into  all  the  parts  of  the  sac,  was  allowed  to  escape. 
No  serious  symptoms  followed  but  the  results  led  him 
after  a  time  to  abandon  its  use. 

Dr.  Pancoast,  of  Philadelphia,  in  his  work  on 
Operative  Surgery,  published  in  1844,  reports  the  in- 
jection of  tincture  of  iodine,  or  tincture  of  cantharides, 
one-half  a  drachm,  introduced  into  the  sac  by  means 
of  a  small  syringe,  fitted  to  a  fine  canula,  which  is 
first  carried  free  into  the  sac.  The  canula  was  with- 
drawn and  a  compress  placed  under  a  truss  directed 
to  be  worn.  All  were  benefited.  The  cases  numbered 
thirteen  and  were  operated  on  in  1836.  Some  worked 
at  farm  labor  a  year  after  the  operation  without  wear- 
ing a  truss,  and  there  was  no  return  of  the  hernia. 


—    145   — 

Dr.  John  Watson,  of  New  York,  published  upon 
the  subject  in  185 1.* 

The  process  of  injection  with  iodine  was  revived 
in  Paris,  in  1854-7,  with  such  results  that  cases  are  re- 
ported by  Boinet,  Demeaux,  Jobert,  Maisonneuve, 
Nelaton  and  Ricord. 

The  injection  method,  of  by  far  the  widest  repute 
and  general  adoption,  is  accredited  to  Dr.  George 
Heaton,  of  Boston.  He  first  published  in  1843.! 
The  material  used  was  a  fluid  extract  of  oak  bark. 

Dr.  J.  H.  Warren,  of  Boston,  the  most  famous  of 
Dr.  Heaton's  followers,  writes:  ''  But  the  honors  of 
the  true  hypodermic  injection,  without  any  preliminary 
incision,  I  think,  after  much  careful  research  in  the 
literature  of  surgery,  belongs  to  the  late  Dr.  George 
Heaton,  of  Boston,  who,  after  eight  years  of  discour- 
aging experiment,  discovered  a  process  which  1  call 
the  method  of  tendinous  ij-ritation^  by  the  injection  of  a 
solution  of  quercus  alba.  Since  he  performed  suc- 
cessful cures,  by  his  new  method,  as  early  as  1840, 
and  experimented,  as  he  tells  us,  eight  years  previous 
to  this,  we  are  carried  back  to  the  year  1832,  when  he 
first  conceived  his  operation.  His  first  operations 
were  with  Dr.  Jaynes  of  St.  Louis."| 


*The  Radical  Cure  of  Reducible  Hernia  by  the  Injection 
of  Tincture  of  Iodine.      N.  Y.  Med.  Times,  1851. 

fBoston  Med.  and  Surg.  Jour.,  1843-4,  p.  217-219. 
:}:Warren  on  Hernia,  Second  Edition,  1882,  p.  129. 

II    DD 


—   146  — 

The  operation,  as  performed  by  Dr.  Heaton, 
created  much  discussion  in  Boston.  It  was  generally 
adversely  criticized,  and  his  methods  were  claimed  by 
some  to  be  unprofessional.  There  can  be  little  doubt 
he  conscientiously  pursued  the  investigation  of  the 
subject  with  enthusiastic  devotion,  and  with  good  re- 
sults, if  not  generally  followed  by  entire  cure. 

Dr.  J.  H.  Davenport  edited  Dr.  Heaton's  book,* 
which  contains  much  that  is  novel  and  interesting. 
There  is  appended  a  list  of  140  cases,  "from  the 
many  hundreds,"  with  brief  notes  of  each. 

Dr.  Warren  began  operating  upon  hernia  by  the 
Heaton  method,  soon  after  the  author's  death.  He 
states,  in  a  note  to  his  second  edition, f  "that  he  is 
convinced  the  credit  of  origination  of  the  method  be- 
longs to  Dr.  Pancoast— that  to  Dr.  Heaton  is  due  the 
discovery  of  the  exceptional  value  of  the  thick  extract 
of  the  oak  bark." 

Dr.  Warren  thinks  that  this  peculiar  effect  is  due 
to  non-absorbability  of  the  particulate  elements  of  the 
bark  and,  by  their  remaining  in  the  tissues,  a  much 
greater  exudation  of  the  cell  elements  occurs. 

Dr.  Warren  greatly  modified  and  improved  the 
instruments  to  be  used,  both  needles  and  syringe,  and 
has  somewhat  changed  the  medicamenta  employed. 
Among  the  recipes  commended,  the  following  is  pre- 
ferred: 


*Cure  of  Rupture.      By  George  Heaton.  Boston,  18,77. 
f  Op.  Cit.   p.  366. 


—   147   — 

3      Fl.  Ext.  Querci  Albae  (reduced 

by  distillation  one  half,    §  ^j- 
Alcohol,  90  per  cent.    |  ss. 
Ether  Sulph.,    5  ij. 
Morphia  Sulphatis,  grs.  iv. 
Tr.  Veratri  Viridis,  M   3  ij 
Inject  from  5  to  20  drops  in  small  and  recent  herniae  but 
25  to  50  drops  in  old  and  larger  herniae. 

Dr.  Warren  further  modified  the  operation  by  in- 
jecting not  into  the  sac,  but  "  into  the  rings  and 
around  the  sac."      This  he  considers  very  important. 

For  a  considerable  time  following  the  publications 
of  Dr.  Warren,  the  operation  was  done  as  he  advised 
in  various  parts  of  America  and  in  Europe.  The 
exudations  which  supervene,  as  I  have  myself  seen, 
are  very  considerable,  the  pain  and  suffering  not  great, 
the  danger  in  competent  hands  slight,  yet  the  results 
are  certainly  not  as  satisfactory  as  the  profession  was 
led  to  expect. 

In  the  fourth  volume  of  The  Transactions  of  the 
American  Medical  Association,  1861,  page  251,  is  a 
most  interesting  paper  by  Dr.  Thomas  Wood,  of  Cin- 
cinnati, upon  the  radical  cure  of  hernia  by  a  sub- 
cutaneous closure  of  the  external  ring  by  suture. 
"  This  is  effected  by  a  needle  constructed  for  the  pur- 
pose, curved  so  as  to  form  about  one-third  of  the 
circumference  of  a  circle  of  two  inches  radius.  It  has 
two  spear  points  with  an  eye  in  the  centre  of  the  shaft, 
large  enough  to  admit  a  silk  braid  one-eighth  of  an 
inch  wide."     The  sac  is  reduced,  the  finger   carried 


—    148  — 

into  the  ring  through  the  invaginated  scrotum,  and 
upon  it  the  needle.  The  cord  protected,  the  needle, 
as  may  easily  be  inferred  from  its  construction,  carries 
the  suture,  enclosing  the  ring  in  a  loop,  and  the  ends 
of  the  suture  are  brought  out  from  opposite  sides. 
These  are  tied  over  a  compress  and  removed  in  from 
ten  to  fifteen  days.  Dr.  Wood  reports  three  opera- 
tions followed  by  cure. 

In  submitting  his  paper  to  the  profession,  he 
states  that  he  does  it,  "  feeling  confident  that  it  will 
be  appreciated  according  to  its  merits.  If  unsuccess- 
ful, it  will  be  allowed  a  peaceful  repose  in  the  common 
sepulchre  of  its  illustrious  predecessors." 

Dr.  John  Wood,  of  London,  first  published  his 
method  of  subcutaneous  operation  by  suture,  in  1857. 
His  experience  is  now  probably  greater  than  that  of 
any  other  living  operator,  and  his  method,  has  been, 
and  is,  so  extensively  in  use,  that  I  copy  from  his  most 
recent  publication  *  his  operation  for  the  radical  cure. 

"This  operation  I  consider  to  be  the  best  for 
cases  of  perfectly  reducible  hernia,  and  especially  for 
those  in  healthy  children  and  young  persons,  in  whom 
truss-pressure  has  been  found  to  have  no  progress 
towards  closing  up  the  aperture,  and  particularly  if 
they  are  likely  to  be  called  upon  for  a  life's  work, 
which  will  remove  them  far  from  instrumental  and 
surgical  assistance,  or  will  render  them  incapable  of 


*  International  Encyclopoedia  of  Surgery,  Vol.  5,  p.  1140. 


—  149  — 
meeting  the  necessary  and  recurring  expenses,  while 
at  the  same  time  it  will  test  and  try  their  physical 
powers  of  resistance.  It  is  also  applicable  to  those 
in  whom  trusses  fail  in  keeping  up  an  increasing  rup- 
ture, or  cause,  in  some  way  or  other,  great  discomfort 
to  the  wearer. 

The  patient  being  placed  on  the  table,  the  parts 
shaved  clean  and  purified,  and  an  anaesthetic  admin- 
istered, so  as  to  get  the  muscles  relaxed,  an  oblique 
incision  is  made  with  a  small,  sharp-pointed  tenotomy- 
knife,  well  washed  in  1-20  carbolic  lotion,  in  the  front 
of  the  scrotum  over  the  fundus  of  the  rupture,  three- 
quarters  of  an  inch  long,  and  through  the  skin  and 
superficial  fascia.  The  handle  of  the  knife  is  then 
used  to  separate  the  integumentary  tissues  from  the 
deeper  fascial  coverings  of  the  hernia,  or  cord,  so  as 
to  form  a  circle  of  detached  integuments  large  enough 
to  be  invaginated  into  the  hernial  canal  without  draw- 
ing up  the  skin  into  the  superficial  ring.  A  stout 
handled  needle,  equally  curved  in  the  segment  of  a 
circle,  with  a  sharp  point,  blunt  shoulders,  and  a  large 
eye  near  the  point  is  used  for  carrying  the  wire.  This 
should  be  well-annealed  and  flexible  copper  wire,  sil- 
vered over,  thick  enough  not  to  cut  the  tissues  when 
drawn  tight,  but  not  so  thick  as  to  be  at  all  inflexible. 
A  piece  about  twenty  inches  long,  briskly  rubbed  so  as 
to  render  it  flexible  and  clean,  dipped  in  a  T-20  solu- 
tion of  carbolic  lotion,  and  then  in  carbolized  oil  (1-5), 
should  have  each  end  bent  into  a  hook  three-quarters 


—  I50  — 
of  an  inch  long,  and  evenly  curved  so  as  to  pass  easily 
through  the  eye  of  the  needle.  The  fore-finger,  oiled, 
should  then  be  passed  into  the  scrotal  puncture,  and 
made  to  invaginate  the  fascia  and  sac  into  the  hernial 
canal,  as  far  as  it  will  go  into  the  deep  ring  behind  the 
lower  fibres  of  the  internal  oblique  muscle,  which 
should  be  raised  well  upon  the  finger.  To  the  inner 
side  of  the  finger  will  then  be  felt  the  raised  edge  of 
the  conjoined  tendon,  lying  on  the  outer  side  of  the 
rectus  abdominis  muscle.  The  needle  must  now  be 
carefully  and  slowly  passed  along  the  finger  until  its 
point  can  be  felt  plainly  by  the  bulb  of  the  digit 
placed  behind  the  conjoined  tendon.  The  point 
should  next  be  directed  inwards  so  as  to  take  up  the 
tendon,  and  to  transfix  it  and  the  aponeurosis  of  the 
external  oblique  which  covers  it.  Its  point  will  then 
be  seen  to  raise  the  skin.  The  skin  must  next  be 
drawn  towards  the  median  line,  and  the  needle  di- 
rected by  its  stout  handle  so  as  to  bring  its  point  out 
through  the  skin,  one  inch  and  a  half  external  to  the 
puncture,  through  the  deeper  tissues.  One  end  of  the 
wire  is  then  hooked  on  to  the  eye  of  the  needle,  and 
is  drawn  with  it  by  a  slight  jerk  through  the  tissues, 
emerging  at  the  scrotal  puncture.  The  needle  is  next 
detached  from  the  wire  and  the  finger  again  passed 
into  the  canal.  Now  the  spermatic  cord  is  to  be  felt 
for,  lying  in  a  groove  formed  by  the  union  of  Poupart's 
ligament  with  the  fascia  transversalis.  The  cord  is  to 
be  pushed  gently  inwards,  and  the  point  of  the  finger 


—    '51  — 
pJlaced  in  the  groove  which  it  occupied,  and  Hfted  for- 
wards, so  as  to  elevate  Poupart's  ligament  at  its  center, 
and  with  it  the  outer  pillar  of  the  superficial  ring. 

The  iliac  artery  may  be  sometimes  behind  the 
finger,  which  lifts  up  the  tendinous  structure  from  its 
immediate  contiguity,  and  protects  the  vessels  from  in- 
jury. The  needle,  passed  again  along  the  front  of  the 
finger,  a  little  to  its  outer  side,  is  then  pushed  through 
Poupart's  ligament  till  its  point  raises  the  skin.  The 
latter  is  now  pulled  inwards  until  the  point  of  the 
needle  can  be  made  to  pass  through  the  same  punc- 
ture in  the  skin  of  the  groin  which  the  wire  already 
traverses.  The  opposite  end  of  the  wire  is  next 
hooked  on  to  the  needle,  drawn  down  as  before 
through  the  scrotal  puncture,  and  then  detached. 
There  is  now  a  wire  loop  at  the  groin,  and  two  hook- 
ends  at  the  scrotal  puncture.  Opposite  the  latter,  the 
sac  is  then  pinched  up  by  the  finger  and  thumb,  in  the 
same  way  that  a  varicocele  is  separated  from  the 
spermatic  duct  when  submitted  to  operation.  An 
assistant  seizes  it  with  finger  and  thumb,  also  in  the 
same  way,  at  about  two  inches  distance,  both  assistant 
and  operator  recognizing  the  situation  of  the  sperm- 
atic duct.  The  needle  is  then  passed  at  one  corner  of 
the  scrotal  puncture  across  the  sac,  in  front  of  the 
duct,  and  out  at  the  other  end  of  the  scrotal  puncture. 
The  skin  here  is  so  elastic  that  the  puncture  stretches 
sufficiently  to  allow  this  to  be  easily  done.  The  inner 
and  of  the   wire — viz.,  that  which   traverses  the   con- 


—   152  — 

joined    tendon — is    next    hooked    on    to  the    eye  o'f 
the    needle    and     drawn     across    behind     the    sac. 
Care  must  here  be   taken,  by  dealing   with  the   wire 
roundly,  not  to  make  an  acute  bend  or  kmk,  which 
would  put  a  needless  difficulty  in  the  way  of   its  sub- 
sequent withdrawal.     The  wire  should  be  drawn  down 
so  as  to  get  straight  parts  in  the  tissues,  and   to  bring 
the  loop  an  inch  or  so  from  the  skin  surface.     The 
two  scrotal  ends  are  then  twisted  twice  or  three  times 
around  each   other,  the   operator  observing  the  direc- 
tion of  the  twist,  so  as  to  be  able  readily  to  untwist 
the  wire  when  it  is  to  be  withdrawn.       The  loop  of 
wire  above  is  now  seized   and   drawn   firmly  upwards, 
so  as  to  invaginate  the  scrotal  fascia  into   the  hernial 
canal   as   high   up   as  the  deep  hernial  opening,  and 
then    it    is    twisted     firmly    down,    in    the    same    way 
and    with  the  same    precautions  as   the    lower    ends. 
The  ends  and  loops  are  then  bent   over  towards  one 
another,  the  former  cut  off   to  a  convenient  length, 
passed  through,  and  bent  on  to  the  latter.     In  very 
large  cases,  where  the  superficial  ring  is  very  patulous, 
the  wires  may  be  crossed  in  the  canal,  and  the  needle 
passed  through  the  pillars    near  the   pubis,  after  the 
sac  is  invaginated.     Thus  the   lower  opening  of  the 
hernial    canal    may  be  more   effectively   closed.       In 
these  cases  a  cylindrical  pad  of  glass  or  boxwood  may 
be  used  with  advantage  to  secure  the  loop,  and  for  the 
ends  of  the  wire  to  be  twisted  over.     A   pad   of  lint, 
large  enough  to  exercise  compression,  is  fixed   under 


—  ^53  — 
the  bight  of  the  double  wire  loop  which  has  been 
formed,  a  little  carbolized  tow  is  put  over  the  scrotal 
puncture  to  catch  any  discharge  and  a  flannel  spica 
bandage  is  applied,  the  ends  of  which,  on  being  tied, 
should  be  made  into  a  sling  or  suspender  to  support 
the  whole  of  the  scrotum  and  penis.  The  patient 
should  be  placed  in  bed  with  the  shoulders  well  raised 
and  the  knees  tied  together  and  bent  over  a  long 
bolster,  with  a  prop  for  the  feet  to  keep  the  body  firm. 
The  bowels  should  be  opened  on  the  morning  of  the 
operation,  and  then  left  until  some  discomfort  is  ex- 
perienced. Opium  should  be  given  for  the  first 
twelve  hours— one  grain  every  four  hours — until  pain 
ceases  or  sleep  comes  on.  The  diet  should  be  of  milk 
and  beef-tea,  with  ice  to  relieve  any  nausea  left  by  the 
anaesthetic.  No  stimulants  are  advisable.  The  pain 
usually  passes  off  in  twelve  hours.  The  discharge  is 
trifling  and  of  a  serous  character.  The  bandage  rarely 
requires  to  be  touched  till  three  days  have  elapsed, 
when  it  may  be  removed  entirely,  with  the  pad  of  lint. 
A  lump  of  well-teased  antiseptic  tow  placed  under  the 
wire  will  be  sufficient  dressing.  The  scrotum  should 
be  well  supported.  In  a  few  cases  the  urine  may  re- 
quire removal  by  a  catheter,  for  the  first  day  or  two, 
on  account  of  the  patient's  inclination  to  contract  the 
abdominal  muscles.  The  wire  should  be  kept  in  from 
eight  to  twelve  days,  according  to  the  amount  of  re- 
action set  up,  the  lower  ends  of  the  wire  acting  as  an 
efficient  drainage  conductor.     At  the  end  of  this  time 


—  154  — 
the  wire  may  be  untwisted,  and  it  will  then  be  found 
that  the  two  parallel,  straight  portions  of  the  wire, 
which  originally  passed  through  different  tracks,  have 
by  slow  ulceration  joined  each  other  in  the  same  track, 
and  that  they  will  come  out  together  by  cutting  off 
their  lower  ends  with  pliers,  and  pulling  upon  the  upper 
loop.  If  by  reason  of  slight  kinks  there  is  any  diffi- 
culty in  this,  the  wire  may  be  straightened  by  pulling 
at  each  end  with  pliers,  and  the  ends  may  then  be 
drawn  together  or  singly.  The  upper  opening  usually 
closes  soon  after  their  withdrawal,  and  a  truss  may 
then  be  applied  with  cotton-wool  beneath  it,  and  the 
patient  may  be  allowed  to  get  up  and  lie  on  a  couch 
until  the  lower  sinus  heals. 

Sometimes  a  little  swelling  of  the  testicle,  or 
effusion  into  the  tunica  vaginalis,  shows  that  the  sper- 
matic cord  is  closely  embraced  by  the  wire,  but  this 
rarely  calls  for  any  special  treatment,  being  entirely 
removed  by  the  wire's  withdrawal.  In  only  one  case, 
in  which  a  steel  clamp  was  used  to  hold  the  ends  of 
the  wire  instead  of  twisting  them,  has  atrophy  of  the 
testicle  followed  the  operation.  I  have  met  with  no 
burrowing  of  matter  since  substituting  the  wire  for 
the  hempen  ligature  and  compress.  The  straightened 
wires  act  as  efficient  and  cleanly  drainage-conductors, 
aided  by  the  raised  position  of  the  shoulders  and 
trunk.  Very  little  discharge  is  usually  present 
throughout,  and  it  only  becomes  purulent  in  the  last 
few  days.     A  large  quantity  of  fibrinous  effusion  mats 


—  155  — 
together   the    walls    of  the    canal  with    the  inclosed, 
invaginated  sac.     The  induration,  however,  soon  dis- 
appears, and  the  cure  depends,  not  upon  its    plug-like 
formation,  but  upon  the  adhesion  of  the   hinder  wall 
of  conjoined  tendon  with  the  front  wall  and  Poupart's 
ligament,  adherent  to  and  embracing  the  cord.      The 
effect    of   this    operation,    when    successfully    accom- 
plished, is  to  unite  in  one  cicatrix  the  sides  of  the  in- 
guinal canal  as  far  up  as  the  deep  ring,  together  with 
the  pillars  of  the  superficial  ring,  the   union  of  which 
supports  the  invaginated,  twisted,  and  obliterated  sac, 
with  its  intimate  coverings   of  external   and  internal 
spermatic    and     cremasteric   fascia.      All   these    are 
blended  together  in  the  fibrinous  effusion  consequent 
upon  the  gradual   severance  by  the  pressure  of  the 
wires.     The  conjoined  tendon  of  the  internal  oblique.. 
and  transversalis  muscles  is  connected  firmly  with  the 
deep  part  of  Poupart's  ligament,  and  upon  this   union 
depends,  for  the  chief  part,  the  success  and  permanence 
of  the  radical  cure.     Thus  the   valvular   arrangement 
of  the  front  and  hinder  walls  of  the   canal  is   restored 
and    strengthened    by    adhesion;    and    the    rounded 
knuckle  of  bowel  can  no  longer  enter  the  deep   ring, 
and  thus,  the  most  effectual  preventive  of  the  forma- 
tion of  a  hernia  in  the  healthy  inguinal   canal,   is  re- 
stored and  even  strengthened  by  the  operation.      Un- 
less this  is  accomplished,  the  cure  is  not  a  satisfactory 
one;  and  one    of  the    chief  causes    of  failure    in  the 
hands  of  beginners  is  the  want   of  dexterity  and   ex- 


—   156  — 

perience  in  obtaining  a  hold  upon  the  conjoined 
tendon  with  the  needle-point,  at  the  first  stage  of  the 
procedure. 

In  some  cases,  no  doubt,  a  want  of  substance  and 
development  in  the  conjoined  tendon  causes  it  to  give 
way  before  the  needle,  and  to  tear  under  the  traction 
of  the  wire.  In  other  cases,  where  the  hernial  rings 
are  large  in  diameter  and  close  to  one  another,  with 
no  length  of  canal  between  them — as  in  direct  hernise, 
and  in  old  oblique  herniae  which  have  become,  in 
effect,  direct,  and  in  which  a  patch  or  plug  of  invagin- 
ated  tissue  is  necessary  to  supply  an  absolute  de- 
ficiency of  the  abdominal  wall — the  inherent  weakness 
will  require  afterward,  perhaps,  a  longer,  or  even  the 
continued  use  of  a  light  truss.  If  care  be  exercised, 
however,  in  placing  and  keeping  on  a  proper  truss, 
such  cases  may  be  strengthened  and  fortified,  so  that 
the  rupture  may  not  return,  and  even  if  the  groin  re- 
mains weak  and  bulgy,  and  threatens  to  reproduce  a 
rupture,  ultimate  success  may  be  obtained.  And  in 
another  class  of  cases,  doubtless,  adhesions,  at  first 
firmly  resisting  and  efficacious  (if  not  deposited  when 
the  patient  is  in  robust  health),  may  yield,  under  con- 
tinued pressure,  just  as  in  other  cases  of  operation  for 
prolapsus  of  various  kinds.  In  less  aggravated  cases, 
the  truss  may  usually  be  left  off  after  nine  or  twelve 
months,  the  patient  being  at  first  careful  to  put  it  on 
occasionally,  when  likely  to  be  called  upon  for  much 
muscular  effort. 


—   157   - 

A  bulgy  weakness  of  the  groin  may  be  apparent 
after  the  hernial  canal  is  securely  closed,  from  a  want 
of  development  in  the  lower  muscular  and  other  fibres 
of  the  internal  oblique  and  transversalis  muscles;  but 
this  condition  rarely  requires  more  than  the  occasional 
use  of  a  light  truss,  such  as  would  be  recommended 
for  weak  groins  which  had  never  been  actually  subject 
to  hernia.  When  it  is  considered  that  in  such  cases, 
generally,  no  truss  has  been  effectual  in  keeping  up 
the  rupture  before  the  operation,  the  advantage  gained 
by  the  latter  becomes  sufficiently  convincing. 

By  the  method  just  described  I  have  operated 
upwards  of  two  hundred  times  consecutively,  with  not 
a  single  seriously  bad  symptom  occurring.  The  aver- 
age period  of  convalescence  has  been  about  a  month, 
from  the  operation  to  the  healing  of  the  lower  open- 
ing; the  average  time  in  bed  about  eighteen  days. 
Before  adopting  the  use  of  the  wire,  thread  and  com- 
presses were  employed,  and  while  the  steps  of  the 
operation  were  imperfectly  understood  and  carried 
out,  and  when,  perhaps  still  more  important,  cases 
were  operated  on  somewhat  indiscriminately,  to  see 
what  could  really  be  accomplished,  three  deaths  oc- 
curred in  the  first  loo  cases;  one  from  pyaemia,  one 
from  erysipelas,  and  the  third  from  peritonitis,  all 
having  been  published  at  the  time  in  the  medical 
journals.  Two  of  these  were  decidedly  from  hospital 
or  other  infection,  while  the  third  case  was  a  peculiar 
one;   the  necropsy  clearly  showed  that  fatal  peritonitis 


-  158  - 
had  been  set  up  by  a  knuckle  of  intestine  which  had 
been  involved  in  the  sac  before  the  operation,  with  the 
truss  pressing  upon  it.  The  focus  of  inflammatory 
action  was  found  around  the  damaged  and  congested 
loop  of  bowel,  on  the  opposite  side  of  the  abdomen  to 
that  which  was  the  seat  of  the  rupture  and  of  the 
operation.  The  sac  operated  on,  and  the  peritoneum 
in  its  neighborhood,  all  around,  were  free  from  all 
traces  or  consequences  of  inflammation.  In  no  case 
has  any  trouble  arisen  from  hemorrhage,  nor  have 
there  been  any  signs  of  injury  to  the  epigastric,  fem- 
oral, iliac,  or  other  vessels."* 

In  the  evolvment  of  thought  in  the  same  direction 
should  be  mentioned  the  operation  by  Dr.  Agnew,  of 
Philadelphia,!  consisting  in  the  use  of  an  instrument 
for  invagination,  and  then  the  subcutaneous  sewing  of 
the  ring  with  wire.  Three  other  sutures,  also  of  wire, 
were  used  to  enclose  the  canal. 

The  late  Dr.  Greensville  Dowell,  of  Texas,  de- 
vised a  most  interesting  modification  of  subcutaneous 
suturing  with  interrupted  silver  wire  sutures,  using  a 
needle  in  shape  like  that  of  Dr.  Thomas  Wood,  of 
Cincinnati,  but  with  an  eye  at  each  end,  instead  of 
the  middle.  The  sutures  were  introduced  in  a  man- 
ner not  unlike  that  of  Dr.  Wood.     He  first  published 


*  International  Encyclopoedia  of  Surgery,  Vol.  V,  p. 
1140-1145. 

f  Medical  and  Surgical  Reporter,  Philadelphia,  1864-5, 
xii,  461,  3. 


—  159  — 
in  1866.*  He  advised  from  one  to  seven  sutures,  as 
required  for  firm  closure.  A  little  before  his  death 
he  reported:!  "The  result  of  my  operations,  as  far 
as  I  can  learn,  is  about  as  follows:  One  hundred  and 
three  cases  treated  by  myself;  twenty-five  cases  par- 
tially relieved,  two  cases,  as  reported,  made  worse. 
One  child  died  in  seven  days  after  operation,  with 
congestion  of  the  brain.  Cures,  seventy-six.  So  far 
as  I  know,  all  these  remain  well;  some  have  had  par- 
tial return  of  the  hernia  and  worn  trusses.  Several 
were  operated  on  twice  and  failed  both  times;  I  know 
no  particular  reason  for  the  failure  except  the  liga- 
tures were  put  in  too  tight.  *  *  *  j  simply  put  a 
piece  of  lint  over  the  ligatures  and  saturate  it  with 
collodion."  I  knew  Dr.  Dowell,  and  greatly  admired 
his  inventive  genius  and  fertility  of  resource.  His 
operation  has  been  performed  by  many  of  his  asso- 
ciates with  excellent  result. 

It  will  be  noticed  that,  in  the  operations  for  sub- 
cutaneous suturing,  the  fundamental  idea  is  not  unlike 
the  old,  abandoned  operations  by  the  "  punctum  aur- 
eum,"  and  suturing  of  the  ring,  in  various  ways,  by 
the  early  fathers  of  surgery.  To  this,  however.  Dr. 
Wood  brought  correct  anatomical  knowledge  and,  by 
the  manner  of  his  suturing,  sought  to  restore  the  ob- 
liquity or  valve-like  character   of   the   canal.     By   the 


*  Medical  Record,  N.  Y.,  Vol.  I,  p.  266. 
t  Warren,  Op.  Cit.,  p.  113. 


—   i6o  — 

rare  tact  and  experience  of  the  master,  he  secured 
better  results,  than  any  operator  preceding  him; 
much  better  indeed  than  his  followers.  Dr.  David  W. 
Cheever,  of  Boston,  Surgeon  City  Hospital,  in  1870^ 
reported  twenty-four  cases,  operated  on  for  cure,  with 
two  deaths.  In  commenting  upon  the  operation,  he 
writes,  "  Hernia  has  long  been  one  of  the  opprobria  of 
surgery.  To  cure  it  no  operation  is  certain.  The 
operation  of  Mr.  Wood  seems  the  most  reasonable  one 
proposed.  It  will  cure  a  certain  number  of  children 
and  young  adults.  It  will  fail  to  cure  others.  Mr. 
Wood,  it  must  be  remembered,  claims  some  70  per 
cent,  of  success.     We  can  show  barely  25   per  cent." 

*  "  During  the  past  five  years,  herniotomy  has 
been  performed  twenty-six  times  for  strangulated  or 
irreducible  hernia.  Thirteen  ruptures  were  inguinal, 
six  died;  twelve  femoral,  five  died;  one  umbilical, 
died. 

Of  eleven  patients  over  fifty  years  of  age  only 
two  recovered;  while  of  fifteen  under  that  age,  twelve 
resulted  favorably.  The  average  duration  of  con- 
valescence was  about  a  month;  in  the  fatal  cases  death 
resulted  at  periods  varying  from  five  hours  to  eigh- 
teen days;  about  five  days  being  the  mean  duration  of 
life.  The  cause  of  death,  so  far  as  could  be  deter- 
mined, was  as  follows:      Exhaustion,   six;  peritonitis, 


*  Medical  and  Surgical  Reports  of  City  Hospital,    Bos- 
ton, 1882,  p.  267,  271.     G.  W.  Gay,  M.  D. 


four;  tetanus,  one;  erysipelas,  one;  total,  twelve,  out 
of  twenty-six  operations." 

'*  Twelve  patients  suffering  from  inguinal  rupture 
were  operated  upon  for  a  radical  cure.  Wood's 
method  was  resorted  to  in  four  instances,  with  tem- 
porary relief.  The  so-called  Heaton  operation  was 
performed  eight  times;  six  cases  were  partially  suc- 
cessful, and  two  were  complete  failures.  All  of  these 
patients  left  the  hospital  wearing  a  truss  or  bandage, 
and  their  subsequent  condition  is  unknown.  No 
radical  operation  has  been  performed  upon  any  of  the 
other  varieties  of  hernia  during  the  past  five  years." 

We  have  ventured  to  give  here  a  brief  account  of 
our  personal  experience  with  the  Heaton  operation, 
and  have  recorded  all  the  cases  operated  on  by  us, 
both  in  hospital  and  private  practice;  the  results  are 
stated  as  fully  as  possible.  All  were  cases  of  inguinal 
hernia,  and  with  the  exception  of  those  specified,  were 
supposed  to  contain  intestine.  Only  those  patients 
are  called  cured^  who  have  remained  well  for  at  least  a 
year  after  discarding  all  support  to  the  rupture." 

'*  Number  of  patients,  fifteen.  Cured,  four.  Re- 
lieved, eight.    Not  relieved,  three. 

Number  of  ruptures,  eighteen.  Cured,  five.  Re- 
lieved, eight.     Not  relieved,  five. 

Number  of  operations,  twenty-three." 

The  criticisms,  which  I  think  we  are  now  in  the 
condition  to  make,  owing  to  the  safety  of  properly 
treated  operative  wounds,  is  that  subcutaneous  surgery 


l62    

is  blind  surgery  and  blind  surgery  is,  as  a  rule,  bad 
surgery.  A  subcutaneous  wound  is  better  by  being 
such,  only  that  it  is  less  liable  to  be,  or  to  become,  an 
infected  wound.  The  problem  of  hernia  as  we  have 
endeavored  to  show,  by  the  careful  study  of  the  anat- 
omy of  the  parts  and  the  formation  of  the  peritoneal 
sac,  is  one  containing  factors  which  necessitate  treat- 
ment by  an  open  wound,  in  order  to  furnish  the  high- 
est measures  of  resultant  cure.  The  peritoneal  sac  is 
a  redundancy  of  extraneous  tissue  and  should  be 
treated  as  a  factor  to  be  eliminated.  This  has  been 
the  stumbling-block  in  the  surgical  treatment  of  hernia, 
during  the  centuries,  often  recognized  as  such,  but  be- 
cause of  the  generally  occurring  septic  infection  of 
open  wounds,  and  high  mortality  when  in  this  locality, 
considered  of  unwarranted  danger.  This  is  one  of  the 
fundamental  faults  in  the  treatment  of  hernia  by  the 
injection,  and  by  the  subcutaneous  suturing  of  the 
ring.  In  both  the  above  methods,  also,  there  is  an  at- 
tempt to  fill  the  ring  by  material,  foreign  to  its  primary 
construction.  In  the  first,  by  a  large  exudate,  often 
incorporating  the  sac; — in  the  second,  when  the  sac  is 
completely  returned,  by  a  portion  of  the  spermatic 
fascia.  Experience  had  long  ago  taught,  that  the 
complete  closure  of  the  canal  and  rings  gave  much  the 
better  result.  It  was  in  recognition  of  this,  that  cas- 
tration became,  for  a  long  time,  the  adopted  method 
and  continued  so,  until  prohibited  by  law,  not  because 
the  hernia  failed  of  cure,  so  much  as  that   a   consider- 


-   i65  - 

able  class  suffered  loss  of  virility,  a  choice  of  evils, 
which  many  voluntarily  made,  when  all  surgery,  at  the 
best,  was  brutal,  as  compared  with  the  present. 

Mr.  Wood,  by  his  subcutaneous  wire  suture,  can 
make  at  the  most  only  two  stitches,  one  to  enclose  the 
internal,  and  one  the  external  ring,  yet  Mr.  Wood 
recognized  the  necessity  of  close  approximation  and 
writes,  "  to  ensure  success,  complete  union  must  be 
established  along  the  whole  length  of  the  canal."  Drs. 
Agnew  and  Dowell  increased  the  number  of  stitches 
in  order  the  better  to  secure  this  result.  In  part,  also, 
to  remedy  this  fault,  the  very  interesting  modification 
of  Mr.  \V'ood's  operation  was  devised,  namely,  the  ex- 
tremely ingenious  and  original  instrument  by  Mr. 
Spanton  f  whose  good  work,  as  an  operator,  in  Eng- 
land is  well  known.  The  cork-screw  instrument  is  at 
once  needle  and  suture  and  is  to  be  commended  for 
its  advantages  over  the  so-called  Wood  suture. 

The  methods  above  described  are  marked  im- 
provements upon  preceding  operations  for  the 
cure  of  hernia.  These  improvements,  however,  are 
but  modifications  of  the  general  idea  which  we  have 
seen  dominated  the  profession  for  centuries;  to  close 
the  canal  by  some  sub-cutaneous  method,  through  the 
fear,  born  of  experience,  of  the  dangers  incident  to 
septic   infections  of  the   locality.       Such  fatality  was 


f  D.    VV.   Spanton,  British  Med.   Jour.,    Lond.  ii,  p.  322, 
:879. 


—  164  — 

quite  sufficient  to  justify  the  general  opinion,  and  it 
required  a  large  amount  of  the  heroism  of  conviction 
to  put  into  execution,  in  operations  undertaken  for 
the  cure  of  hernia,  the  methods  of  antiseptic  wound 
treatment. 


CHAPTER  X. 

THE  OPERATION    FOR    THE    CURE    OF    HERNIA 

BY  THE    OPEN  WOUND  METHOD  UNDER 

ANTISEPTIC    PROTECTION. 

The  revolution  in  the  surgical  treatment  of 
wounds  had  its  inception  with  Sir  Joseph  Lister, 
whose  marvellous  genius  and  indefatigable  industry 
surmounted  all  obstacles. 

His  inspiration  came  from  the  studies  of  Pasteur 
and  others,  including  our  own  Professor  Jeffreys  Wy- 
man,  upon  fermentation  and  its  dependence  upon 
vital,  rather  than  chemical  causes.  The  results  of 
his  labors,  for  the  benefit  of  his  race,  have  never  been 
exceeded  by  any  devotee  to  the  healing  art,  and  his 
name  must  be  indissolubly  associated  with  the  treat- 
ment of  wounds,  so  long  as  surgery  remains  a  branch 
of  science.  By  rare  good  fortune  I  received  his 
personal  instruction  at  Edinburgh,  in  1870.  The 
demonstration  seemed  complete  that  in  an  aseptic 
wound  thus  retained,  repair  goes  on  under  the  same 
favorable  conditions  as  in  subcutaneous  wounds.  The 
factors  in  the  problem  to  be  solved  were,  the  best 
methods  of  preventing,  contamination  in  the  wound 
when  open,  and  retaining  it  uninfected  during  the 
process  of  repair.  In  all  operative  measures,  the 
ligation  of  the  larger  arteries  is  often  an  important 
consideration.     As  done   during  the   earlier   part  of 


—  i66  — 

Mr.  Lister's  investigations,  it  was  so  defective,  that 
often  about  the  ligature  dangerous  processes  super- 
vened. In  the  research  for  better  material  for  liga- 
tures, Mr.  Lister  experimented  with  the  strings  of  the 
violin.  Satisfied,  that  in  carbolic  acid,  he  had  found 
a  safe  and  comparatively  non-irritating  agent  for  the 
protection  of  the  open  wound,  he  made  application  of 
it  for  the  better  preparation  of  ligatures.  Its  effects 
upon  the  catgut  when  steeped  in  it  appeared  to  change 
its  constituency  so  as  not  only  to  render  it  innocuous  in 
wounds,  but  when  incorporated  in  the  tissues,  for  a 
considerable  period,  to  resist  maceration.  Happy  in 
the  knowledge  of  such  facts,  Mr.  Lister  instituted  a 
series  of  experiments  in  the  ligation  of  the  larger 
vessels  in  animals  and  found  that  when  aseptically  ap- 
plied they  were  in  considerable  measure  replaced  by  a 
vivified  connective  tissue. 

Upon  the  19th  of  February,  187 1,  in  consultation 
with  Dr.  A.  P.  Clarke,  of  Cambridge,  I  operated  upon 
Mrs.  M.,  aged  50,  who,  for  years,  had  suffered  from 
hernia.  Five  days  before,  she  was  seized  with  severe 
pain  in  the  inguinal  region,  accompanied  by  vomiting. 
Long-continued  and  careful  taxis  had  failed  to  re- 
duce the  hernia,  and  for  twenty-four  hours  the  vomit- 
ing had  been  stercoraceous,  and  the  patient  seemed 
in  extremis.  The  hernial  tumor  was  of  the  size  of  an 
egg,  protrudmg  from  the  external  inguinal  .ring.  A 
careful  dissection  exposed  the  sac,  which  was  closely 
adherent  to  the  surrounding  parts.     The  constriction 


was  aL  the  internal  ring  and  was  divided  with  some 
difficulty.  The  hernia  was  reduced  and  the  sac,  un- 
opened, was  returned  within  the  ring.  Two  stitches 
of  medium-sized  catgut  were  taken  directly  through 
the  pillars  of  the  ring. 

The  wound  was  dressed  antiseptically,  and  from 
Dr.  Clarke's  notes,  taken  at  the  time,  I  find  that  the 
patient  complained  of  no  pain,  steadily  progressed 
without  accident,  and  was  convalescent  in  three 
weeks.  The  result  was  a  radical  cure  of  the  hernia, 
although  the  canal  was  not  closed  for  this  purpose. 
The  opening  into  the  abdomen  was  so  large  that  we 
feared  the  escape  of  contents,  especially  since  the 
woman  v/as  afflicted  \vith  a  severe  chronic  bronchitis. 
It  was  expected  that  the  sutures  would  hold  the  parts 
in  situ  temporarily.  She  died  six  years  after  the 
operation,  and  was  troubled  with  the  cough  during 
the  entire  period,  but  the  canal  remained  firmly  closed 
at  death.  She  did  not  wear  a  truss  after  the  opera- 
tion. 

March  lo,  1871,  assisted  by  Dr.  W.  W.  Welling- 
ton, of  Cambridge,  I  operated  on  Mrs.  L — ,  aged  45, 
suffering  with  strangulated  hernia.  The  hernia  was 
of  some  years'  standing,  and  usually  retamed  by  a 
truss.  It  was  on  the  left  side  and  direct  inguinal  in 
variety.  The  sac  was  returned  unopened,  the  canal 
was  closed  by  three  large  sized  cat-gut  sutures,  taken 
deeply  through  the  pillars  of  the  ring,  and  the  wound 
carefully  dressed  antiseptically  with  Lister's  carbolized 


—  i68  — 

lac  plaster.  When  examined  the  following  June,  the 
cicatrix  was  linear,  and  a  firm  deposit  of  new  tissue 
could  be  felt,  marking  the  site  of  the  buried  sutures. 
The  cure  remained  permanent,  and  the  patient  wore 
no  support. 

I  reported  these  cases  at  the  meeting  of  the 
County  Medical  Society,  October  ii,  187 1,  and  they 
were  published  in  the  Boston  Medical  and  Surgical 
Journal,  November  16,  187 1,  under  the  title,  ''A  New 
Use  of  Carbolized  Cat-gut."  In  closing,  I  remarked: 
"  As  far  as  my  observation  has  extended,  this  is  a  new 
use  of  the  carbolized  cat-gut  ligature,  and  suggests  a 
still  wider  field  of  application.  No  method  of  opera- 
tion for  the  radical  cure  of  hernia  appears  more  feasi- 
ble, is  probably  attended  with  less  danger,  and,  at  the 
same  time,  affords  a  means  of  closing  and  strengthen- 
ing the  weakened  ring,  which  is  so  desirable,  and  yet, 
with  all  the  ingenious  devices  of  surgery,  is  so  difficult 
to  obtain."  * 

A  thoughtful  observer  could  not  help  profiting 
by  results  of  such  value.  After  a  review  of  Mr. 
Lister's  studies  upon  the  cat-gut  ligature,  as  applied 
to  the  constriction  of  arteries  in  continuity,  I  instituted 
a  series  of  experiments  on  animals,  with  careful  histo- 
logical studies  upon  the  changes  which  animal  sutures, 
cat-gut  and  the  tendons  of  animals  undergo  when 
buried  in  the  tissues. 


*  Boston  Medical  and  Surgical  Journal,  Vol.  viii,  p.  316. 


—  169  — 

Upon  these  facts  and  deductions  so  fundamental, 
I  determined  that,  about  the  site  of  the  suture,  there 
results  a  deposition  of  connective  tissue  cells,  which 
in  a  considerable  measure  replace,  almost  cell  by- 
cell,  the  dead,  aseptically  preserved  tissue,  by  a  living, 
vascular  growth. 

These  changes  varied,  dependant  upon  the  con- 
dition of  the  incorporated  part.  If  the  suture  or 
wound  is  septic,  the  conditions,  then  called  inflamma- 
tory, ensue,  the  tissues  become  reddened  and  swollen, 
leucocytes  are  poured  out  along  the  tract  of  the  suture 
and  abscesses  result.  If  aseptic,  and  yet  not  chemic- 
ally changed,  to  prevent  rapid  maceration,  the  threads 
speedily  disappear  with  only  a  moderate  exudate, 
which  is  soon  absorbed.  If  more  resisting,  the  ensuing 
changes  go  on  more  slowly  with  much  greater  cell  in- 
filtration. There  is  found  to  be  a  limit  of  apparently 
a  chemical  change  in  the  fibres  of  the  suture,  beyond 
which  the  softening  goes  on  too  slowly,  and  sometimes 
a  part,  especially  a  knot,  is  eliminated  as  a  foreign 
body. 

The  considerable  supply  of  cat-gut,  which  I 
brought  with  me  from  Europe,  was  made  under  the 
immediate  supervision  of  Mr.  Lister  and  kept  per- 
fectly. Subsequently,  I  prepared  the  catgut  and  ten- 
don sutures  which  I  used  after  his  formula. 

It  is  probable  that  the  honor  of  first,  in  modern 
times,  putting  animal  ligatures  to  the  test  in  surgery, 
is    due    to    the    late    Dr.    Physick,    of   Philadelphia, 


—  lyo  -- 

although  Dr.  Thomas  Young,  of  Edinburgh,  in  his 
''Introduction  to  Medical  Literature,"  published  in 
1813,  wrote,  •'!  have  often  wished  to  try  ligatures  of 
cat-gut  which  might  be  absorbed." 

Dr.  Physick  made  his  ligatures  of  Chamois  skin. 

The  immortal  McDowell  who  first  performed 
ovariotomy,  ligatured  the  pedicle  with  narrow  strips 
of  Indian  tanned  deer  skin,  and  returned  the  stump 
within  the  abdominal  cavity.  Dr.  Paul  Eve,  of  Ten- 
nessee is  attributed  to  have  used  similar  ligatures  and 
also  those  made  of  the  dried  tendon  of  the  deer. 

Illustrating  the  old  maxim,  that  "there  is  no  new 
thing  under  the  sun,"  we  read  the  teachings  of  to-day^ 
in  the  Arabic  works  of  the  celebrated  Rhazes  who 
practiced  in  Bagdad,  A.  D.  900;  and  again,  a  century 
or  more  later,  in  Albucassis  who  wrote  of  the  closing 
of  abdominal  wounds  with  lute  strings,  and  of  the 
stitching  together  of  wounded  bowels  with  fine 
threads,  made  from  the  intestines  of  the  sheep. 
Homer,  in  the  Odyssey,  states  that  the  harp-strings  of 
the  Greeks  were  thus  made.  In  similar  manner  also 
was  strung  the  harp  of  the  ancient  Egyptians,  and  it  is 
very  probable  cat-gut  ligatures  and  sutures  were  not 
unknown  at  the  time  of  the  Pharaohs. 

A  considerable  number  of  our  best  surgeons  con- 
demned cat-gut,  after  a  few  trials,  because  of  unsatis- 
factory results.  Reports  of  failure  in  the  cure  of 
hernia  on  account  of  too  speedy  absorption  were  made 
to  me  as  early  as  1876.     Believing  this  must  be  from 


—   171   — 

faulty  material,  if  aseptically  applied,  1  entered  upon 
an  extended  research,  intending  to  cover  the  entire 
field  of  animal  sutures. 

The  cat-gut  prepared  in  Italy  is  deservedly  most 
highly  prized  by  musicians.  This  is  made  from  the 
mountain  sheep,  more  active  and  less  fat  than  ordin- 
ary domestic  sheep.  The  connective  sheath  of  the 
intestine  is,  on  this  account,  less  fatty  and  stronger; 
yet  in  the  process  of  manufacture  it  is  split  into  ribbon- 
shaped  pieces,  closely  twisted,  and  after  drying,  is 
often  sandpapered  to  give  an  even  surface,  and  by 
thus  cutting,  it  is  much  weakened.  These  processes 
greatly  injure  the  product  for  surgical  purposes. 
Many  specimens  examined,  after  maceration,  show, 
in  the  cross  cutting  of  the  fibres  and  irregular  edges, 
good  cause  for  yielding  in  the  tissues,  although 
capable  of  high  tension  in  the  dry  state.  The  long 
maceration  which  the  intestine  has  to  undergo  in  the 
preparation  for  the  separation  of  the  connective  tissue 
sheath  is  also  productive  of  injury.  In  this  state  the 
entire  mass  is  usually  in  a  condition  of  active  putre- 
faction for  some  days,  and  infective  material  may  re- 
main in  it  through  its  subsequent  stages  of  prepara- 
tion. 

The  parallel  bands  of  connective  tissue  which 
make  up  the  tendons  of  animals  came  naturally  to  be 
considered  as  furnishing  suitable  material  for  surgical 
purposes.  In  the  dried  state,  these  were  used  to  some 
extent  a  generation  ago.     I  obtained  excellent  speci- 


—    172    — 

mens  in  quantity,  two  feet  long,  from  the  tendons  of 
the  hind  leg  of  the  moose  and  caribou  of  Northern 
Maine.  They  divide  into  comparatively  fine  threads 
and  are  chromicized.  I  found  the  tendons  from  the 
tail  of  the  whale,  although  often  four  feet  in  length, 
fatty  and  liable  to  fray.  Upon  the  western  plains  I 
was  taught  by  the  Indians  the  way  the  women  use  the 
fascia  lata  of  the  buffalo  in  sewing  skins.  These  also 
proved  not  well  suited  for  surgical  use. 

In  1880,  Dr.  P.  G.  Simmons,  of  Charleston,  S.  C, 
sent  me  fine  specimens  of  tendons  from  the  tail  of  the 
large  southern  fox  squirrel,  which  he  had  used  with 
much  satisfaction.  They  were  perfection,  except  in 
length.  Knowing  that  a  similar  long  tendon  extended 
through  the  tail  of  the  kangaroo,  I  sent  to  Australia 
and  obtained  a  supply  from  the  hunters  in  1882. 
These  proved  all  that  could  be  desired,  and  I  have 
used  them  constantly  since,  and  for  sutures  and  liga- 
tures consider  them  in  every  way  superior  to  any  other 
material.  I  have  fine  specimens  of  the  spun  fibre 
from  whale  tendons,  prepared  in  Japan,  and,  some- 
what recently,  am  indebted  to  a  medical  gentleman  of 
Russia  for  some  excellent  sutures  made  in  this  way 
from  the  tendon  of  the  reindeer. 

Although  I  had  continued  to  operate,  from  time 
to  time,  as  occasion  demanded,  upon  cases  of  strangu- 
lated hernia,  and  in  each  case  had  closed  the  ring 
with  continuous  buried  animal  sutures,  it  was  not 
until  February  4,  1878,  that  I  deliberately  attempted 


—  173  — 
a  cure  for  a  reducible  hernia.  This  patient  I  had, 
some  time  previous  (Dec.  2,  1877),  cured  of  a  large 
old  irreducible  omental  hernia  which  had  become  com- 
plicated by  a  strangulated  loop  of  intestine.  In  this 
instance,  I  dissected  the  sac  and  resected  the  omen- 
tum. I  closed  the  neck  of  the  sac  with  a  continuous 
cat-gut  suture,  excised  the  sac,  and  returned  before 
suturing  the  ring. 

A  truss  retained  imperfectly  a  large  direct  in- 
guinal hernia  of  the  left  side,  for  which  she  be- 
sought cure,  although  seventy  years  of  age.  1  was 
aided  by  Dr.  A.  L.  Norris,  of  Cambridge,  who  cheer- 
fully gave  me  his  approval.  In  this  I  was  the  more 
fortunate,  since  until  that  time  my  advocacy  of  opera- 
tive measures  for  the  cure  of  hernia,  in  non-strangu- 
lated cases,  had  not  met  with  approval.  The  opera- 
tion was  not  difficult  and  the  result  satisfactory.  On 
the  17th  of  April  following,  she  died  of  an  aneurysmal 
tumor  of  the  brain.  The  autopsy  gave  me  two  excel- 
lent specimens  of  different  dates,  showing  not  only 
the  histological  changes  which  ensued  about  the 
suturing,  but  the  conditions  of  the  underlying  peri- 
toneum. In  the  first  operation,  where  the  sac  had 
been  sutured  and  resected  before  closure  of  the  ring, 
the  peritoneum  was  perfectly  smooth  and  without  de- 
pression, at  the  former  site  of  the  ring.  Upon  the 
opposite  side,  where  the  sac  had  been  returned  un- 
opened, there  remained  a  little  pouched  depression  of 
peritoneum,  which  taught  the  ease  of  reformation  of 


—  174  — 
hernia.  These  specimens,  I  presented  to  the  Ameri- 
can Medical  Association,  at  the  annual  meeting  held 
in  June,  and  communicated,  at  considerable  length, 
my  views  of  the  operation  for  the  cure  of  hernia,  by 
the  buried  animal  suture.* 

I  gave  in  this  paper,  the  history  of  the  animal 
suture  and  its  preparation  for  surgical  uses,  since  few 
surgeons  at  that  date,  even  in  England  used  cat-gut 
for  the  ligation  of  vessels. 

In  a  farther  communication  upon  the  cure  of 
hernia,  to  the  International  Medical  Congress,  held  in 
London,  1881, 1  emphasized  the  freeing  of  the  sac,  and 
its  resection,  after  sewing  it  across  at  its  base  with  a 
continuous  animal  syture,  and  then  refreshing  the 
pillars  of  the  ring,  and  closing  by  deep  buried  con- 
tinuous sutures  of  tendon,  which  are  much  to  be  pre- 
ferred to  cat-gut.  I  summarized  the  advantages  of 
this  method  of  operation  as  follows: 

"  I.  We  are  enabled  to  see  clearly  each  and  every 
step  of  the  operation;  blind  surgery  is  bad  surgery,  as 
a  rule. 

II.  It  is  the  only  method  with  which  I  am  ac- 
quainted by  which  the  hypertrophied,  elongated,  peri- 
toneal pouch,  which  has  been  a  primal  factor  of  fail- 
ure, hitherto,  can  be  removed. 

III.  Hereby,  we  actually  reinforce,  as  well  as 
occlude  the  ring.     In  the  weakened,  attenuated   con- 


*  Trans.  American  Medical  Association,  vol.  29,  1878. 


—  175  — 
dition  of  the  parts,  in  all  old  cases,   there    is  no  small 
gain  in  securing  such  effect. 

IV.  Experience  has,  I  think,  now  demonstrated 
that  this  operation  may  be  catalogued  among  those 
safely  advised,  and  that  femoral  and  umbilical  hernia 
are  no  exceptions.  I  would  not  exclude  children 
irom  the  class  to  be  benefited  for  in  them  the  vital 
processes  are  at  the  best,  and  when  thus  cured  they 
are  saved  from  a  life-long  disability."* 

In  May,  1886,  I  contributed  to  the  American 
Medical  iVssociation  a  further  report  upon,  "  The 
Radical  Cure  of  Hernia,"  based  upon  a  series  of  thirty 
operations,  in  which  I  show  that  in  my  hands  the 
operation,  as  such,  has  been  devoid  of  danger.  I  con- 
clude the  paper  by  recommending  the  advisability  of 
the  operation  by  the  buried  tendon  suture  after  resec- 
tion and  closure  of  the  sac, 

"  I.     In  all  cases  of  operation  for  strangulation. 

II.  In  all  cases  where  the  abdominal  contents 
are  imperfectly  retained  by  an  instrument,  unless  the 
age  and  condition  of  the  patient  prevent. 

III.     In   the  large  class  of    children,    when    the 
conditions  do  not  promise  a  spontaneous  cure.f " 

The  first  case,   of  which  I   find  record,  after  my 


*rrans.  international  Med.  Congress,  Vol,  ii,  p.  446. 
fJournal  American  Medical  Association,  May  28,  1887. 


-  176- 

own,  where  the  canal  was  closed  by  animal  sutures,  is 
that  by  Mr.  Charles  Steele,  of  Bristol,  England.  May, 
1873,  The  operation  was  performed  on  a  boy  of  eight 
years,  and  the  canal  closed  by  two  catgut  sutures. 
The  recovery  was  rapid  and  the  boy  remained  for  six 
months  cured,  when  strangulation  occurred,  and  the 
operation  was  repeated  with  three  sutures.  The  re- 
covery was  perfect  and  a  truss  applied.  When  re- 
ported the  cure  remained,  and  the  parts  were  firm." 

Mr.  Steele  says:  "  While  I  thought  out  and  per- 
formed  this  operation,  as  an  original  matter,  I  do  not 
assert  that  I  originated  the  operation;  in  fact,  it  seems 
to  me  the  most  likely  measure  to  suggest  itself  to  any 
surgeon's  mind  when  considering  the  subject,  and  I 
dare  say  several  have  performed  it.*" 

Prof.  Thomas  Annandale,t  of  Edinburgh,  oper- 
ated upon  a  case  of  strangulated  femoral  hernia,  in 
January,  1872,  in  which  he  tied  the  neck  of  the  sac 
with  catgut,  and  removed  it  with  some  adherent 
omentum.  The  result  was  so  satisfactory  that  Mr. 
Annandale  states:  "  I  have  adopted  this  method,  in 
all  cases,  since  operated  on;  but  during  the  last  two 
years,  I  have,  in  addition,  stitched  the  margins  of  the 
abdominal  opening  together."  He  commends  un- 
hesitatingly, ''  ligature  of  the  neck  of  the  sac,  with  ex- 
cision of  the  sac,  and  stitching  together  the  margins  of 


♦British  Medical  Journal,  Nov.  7,  1874,  p.  584. 
f Edinburgh  Med.  Jour.  Dec,  1880. 


—  177  — 
the  abdominal  opening."  He  uses  catgut  and  Listerian 
antiseptics. 

To  Prof  Czerny,*  of  Heidelberg,  is  accredited  the 
origin  of  the  operation  by  the  open  method,  for  the 
radical  cure  of  hernia,  in  Germany.  His  first  case 
was  a  strangulated  hernia,  of  a  child,  two  and  a  half 
years  old,  operated  on,  October  21,  1877. 

The  canal  was  closed  by  two  sutures  of  silk. 

The  wound  became  septic  with  abscess,  but  the 
cure  was  complete  two  years  later.  There  are  re- 
ported nineteen  radical  operations  upon  sixteen  pa- 
tients. Complete  ligation  of  the  neck  of  the  sac  was 
made  in  nine  cases.  Suppuration  supervened  thirteen 
times.  Silk  was  used  as  suture.  The  canal  was 
closed  in  four  cases. 

Schede'sf  first  case  of  operation  fgr  cure  was  a 
double,  reducible,  inguinal  hernia  which,  in  con- 
sequence of  the  large  size  of  the  rings,  could  not  be 
retained  by  a  truss. 

The  operation  was  performed  by  freeing  the  sac, 
drawing  it  down  as  far  as  possible,  ligating  it  at  the 
neck,  and  resecting.  On  one  side,  a  piece  of  omen- 
tum was  included  in  the  ligature  and  removed. 

The  cure  was  complete,  although  the  rings  were 
previously  large  enough  to  admit  three  fingers. 

He  reported  in  connection  a  series  of  eight  cases. 


*  Berlin  Klin.  Wochenschr.     No.  4,  1881. 

f  Max  Schede  Ccntralblatt  fiir  Chirurgie  Nov.  1877. 


13    DD 


m  nwmi  sawsTWJUM  mmm 


-  178  - 

the  primary  operation  in  all  was  the  obliteration  of 
the  sac.  The  character  of  the  ligature  is  not  men- 
tioned. He  states  the  difficulty  of  applying  a  perfect 
antiseptic  dressing  in  this  region  of  the  body  is  very 
great,  on  account  of  atmospheric  contamination  and 
the  contact  of  urine,  especially  in  children.  Also 
he  gives  the  opinion  as  to  the  final  result  that,  in 
the  majority  of  cases,  the  operation  can  only  be  ex- 
pected to  put  the  patient,  in  such  a  state,  that  the 
wearing  of  a  truss  will  prevent  the  future  prolapse 
of  the  hernia.* 

The  interesting  monograph  of  Victor  Cuenod  f 
gives  the  work  of  Professor  Socin,  in  the  hospital  at 
Basle,  from  1877  to  1881,  in  the  operations  for  the 
cure  of  hernia. 

The  results  are  so  interesting  and  important  that 
I  append  a  brief  abstract. 

Prof.  Socin,  having  carefully  disinfected  the 
parts,  and  the  bowel  having  been  properly  emptied, 
by  means  of  mild  purgatives,  if  necessary,  proceeds  as 
follows: 

ist.  Incision  of  skin  and  subjacent  tissues  as 
far  as  the  sac. 

2d.  Dissection  and  isolation  of  the  sac,  effected 
by  soft  instruments  or  with  the  finger;  if  this  dissec- 


*  Berlin  Klin.  Wochen.  Schr.  No.  4,  1881. 
f  Etude  Du  R6sultat  Definitif  dans  la  Cure  Radicale  Des 
Hernias.     Victor  Cuenod.     1881. 


—  179  — 
tion  is  not  possible,  preparation  of  the  neck   so   as  to 
be  able  to  constrict  it. 

3d.  Incision  of  sac,  reduction  of  its  contents, 
after  freeing  the  constricted  ring,  if  it  is  a  strangu- 
lated hernia,  if  necessary,  resection  of  the  adherent 
omentum. 

4th.  Simple  ligature,  double,  triple,  or  quadruple 
of  the  neck,  carried  as  high  as  possible,  and  excision 
of  the  sac. 

5th.     Suture  of  the  pillars,  when   it  is   necessary. 

Finally,  the  aponeurosis  which  covers  the  sac  is 
often  brought  together  with  sutures,  the  cavity  is 
drained,  disinfected,  and  the  edges  of  the  skin  are 
united  by  sutures.  A  Lister  dressing,  very  carefully 
applied  and  well  compressed  covers  the  wound. 

Monsieur  Socin  considers  it  useless  to  refresh  the 
edges  of  the  ring,  and  has  not  practiced  it  upon  the 
cases  here  reported.  It  is  only  rarely,  in  cafees  of  in- 
guinal hernia,  that  he  sutures  the  ring.  In  one  or 
two  cases  of  crural  hernia,  with  a  large  opening  he 
has  found  it  necessary  to  bring  together  the  borders 
of  the  orifice,  in  order  to  secure  occlusion. 

Finally  in  inguinal  hernia,  the  presence  of  the 
spermatic  cord  is  one  of  the  most  serious  obstacles  to 
the  complete  success  of  the  operation.  It  is  evident 
that  complete  obliteration  of  the  hernial  canal  will  be 
more  diffcult,  since  the  surgeon  is  obliged  to  leave  in 
this  canal  a  moveable  organ,  subject  to  difference  in 
size  and  frequent  movements.      In  women,  the  pre- 


—   i8o  — 

sence  of  the  round  ligament  is  of  much  less  import- 
ance and  needs  to  be  considered  only  in  pregnancy 
and  delivery. 

It  is  doubtless  owing  to  these  anatomical  condi- 
tions that  we  must  attribute  the  difference  in  results 
obtained  between  inguinal  and  crural  hernia.  In  the 
first,  the  passage  of  the  hernia  is  made  through  a 
canal  already  formed  which  can  be  only  narrowed  and 
not  completely  obliterated  after  the  operation,  while 
in  the  second,  this  passage  is  made  through  a  simple 
orifice,  of  which  the  complete  occlusion  will  be  much 
easier  to  secure. 

Report  of  his  cases  from  1877  to  1880  which  were 
operated  upon  in  the  Hospital  at  Bale. 

"  Sur  17  hernies  non-incarcerees,  il  y  avait  15 
hernies  inguinales  et  2  crurales. 

Sur  17  hernies  incarcerees,  il  y  avait  10  hernies 
inguinales  et  7  crurales,  giving  as  result: 

Sur  17  hernies  non-incarcerees,  9  relapses,  8  cures. 
Sur  17  hernies  incarcerees,  3  relapses,  i^  cures. 

Or  more  exactly: 

Sur  15  hernies  inguinales  non-incarcerees,  9  relapses,  6 
cures. 

Sur  2  hernies  crurales  non.incarc6r6es,  o  relapses,  2 
cures. 

Sur  10  hernies  inguinales  incarcerees,  i  relapse,  9  cures. 

Sur  7  hernies  crurales  incrarc6r6es,  2  relapses,  5  cures. 

This  gives,  as  percentum,  in  classes: 


—   i8i  — 

For  non-incarcerated  hernia,  52.9  per  cent,  relapses,  47.1 
per  cent,  cures. 

For  incarcerated  hernia,  17.6  per  cent,  relapses,  82.3  per 
cent,  cures. 

And  in  varieties: 

Inguinal  non-incarcerated,  60  per  cent,  relapses,  40  per 
cent,  cures. 

Crural  non  incarcerates,  60  per  cent,  relapses,  100  per 
cent,  cures. 

Inguinal  incarcerated,  10  per  cent,  relapses,  90  per  cent, 
cures. 

Crural  incarcerated,  18.5  percent,  relapses,  71  per  cent, 
cures. 

These  cases  had  all  been  heard  from  as  to  their 
condition  from  nine  to  forty-three  months  after  the 
healing  of  the  wound. 

Of  the  twenty-two  cures,  eight  were  males,  four- 
teen females;  as  to  age,  as  follows: 


AGE  OF 

PATIENTS 

CASES 

PATIENTS. 

CURED. 

OPERATED    UPON, 

I — 10  years. 

2 

2 

10—15     " 

I 

15—20     " 

2 

20 — 30     " 

I 

30—40     " 

3 

40—50     " 

5 

50—60     " 

5 

II 

60—70     " 

2 

70—80     •• 

I 

Conclusions: 

**  I.     The  result  of  so-called  radical  cure  can  be 


considered   definite,  only  about  two    years  after  the 
operation. 

2.  The  chances  of  success  exceeding  greatly 
non-success  in  children,  the  radical  operation  is  indi- 
cated, with  this  class,  always  where  the  hernia  cannot 
be  retained  with  a  bandage. 

3.  The  radical  operation  is  indicated  in  adults 
and  aged  persons,  in  all  cases  where  a  bandage  cannot 
be  supported  or  efficacious  in  its  action. 

4.  The  ablation  of  the  sac  and  suture  of  the 
neck  in  no  way  complicates  the  operation  of  kelotomy, 
but  increases,  on  the  contrary,  the  chances  of  success 
of  the  operation,  and  should  always  be  practiced  in 
strangulated  hernia." 

M.  Tilanus  reported  to  the  Congress,  held  at 
Amsterdam,  in  1879,  a  statistical  paper  upon  the  anti- 
septic operations  performed  for  the  cure  of  hernia. 
He  collected  reports  of  about  one  hundred  cases,  by 
different  surgeons,  with  only  eleven  per  cent,  of  cures. 
He  advised  excision  of  the  sac  and  deep  sutures. 

M.  Championniere,  of  Paris,  in  1880,  recom- 
mended the  excision  of  the  sack  with  scarification  of 
the  neck  and  deep  sutures;  sometimes  a  retaining 
suture  of  silver. 

Mr.  W.  Mitchell  Banks,*  of  Liverpool,  contributed 
an  article,  in  1882,  upon  the  radical  cure  of  hernia  by 
the  removal  of  the  sac,  and  the  stitching  together  the 


*  British  Medical  Journal,  London,  1882,  p.  985-8. 


-   i83  - 
pillars  of  the  ring.     His   first   reported  operation  was 
in  January,  1880. 

In  August,  1887,  at  the  meeting  of  the  British 
Medical  Association,  Mr.  Banks  reported  a  tabulated 
list  of  106  cases  with  an  analysis.*  Sixty-eight  cases 
were  without  strangulation;  in  38  strangulation  was 
present.  "The  operation  which  I  have  adopted  is 
this:  In  inguinal  hernia,  the  sac,  after  being  cleanly 
dissected  out,  is  opened,  and  all  bowel  is  replaced, 
and  adherent  omentum  tied,  and  cut  away.  The  sac 
is  then  well  pulled  down,  ligatured  as  high  up  in  the 
canal  as  possible,  and  removed.  Finally,  the  pillars 
of  the  ring  are  brought  together  by  two  or  three  silver 
ligatures,  which  are  left  in  position. 

In  femoral  hernia,  the  cleaning  and  removal  of  the 
sac  constitutes  the  whole  operation,  and  no  attempt  is 
made  to  close  the  femoral  aperture.  In  ventral  and 
umbilical  hernia,  use  is  frequently  made  of  the  whole 
or  part  of  the  sac,  as  a  kind  of  plug  to  stop  the  aperture, 
which  is  generally  large,  and  in  which  it  is  seldom 
possible  to  adopt  any  means  of  approximating  the 
edges  which  seem  likely  to  be  permanent." 

In  the  analysis  of  his  tables  Mr.  Banks  states 
''that  in  the  sixty-six  cases  which  he  has  been  able  to 
follow  up,  forty-four  were  completely  successful  from 
a  curative  point  of  view."  Mr.  Banks  does  not  con- 
sider the  truss  such  a  serious  inconvenience,  and  would 


*  British  Medical  Joumal,  August  10    1SS7,  p.  1259-61. 


—   i84  — 

not  operate  where  the  rupture  could  be  retained.  He 
also  "  advises  everybody  to  wear  a  light  support  after 
operation."  "All  parings,  scrapings  and  freshetiings 
of  the  inguinal  canal  I  hold  to  be  utter  nonsense,  and 
quite  theoretical.  When  an  inguinal  hernia  is  big 
enough  to  warrant  operation,  there  is  commonly  little 
canal  or  ring  left.  I  have  generally  found  a  big  hole 
with  a  thin-edged  margin,  which  has  taken  three  or 
four  fingers  of  an  assistant  to  plug  up,  while  the  sac 
was  being  removed.  Then  what  is  the  use  of  pulling 
the  pillars  together  by  sutures  ?  I  do  it  simply  to  hold 
the  parts  together  temporarily  while  the  wound  heals, 
so  as  to  prevent  all  danger  from  coughing  or  strain- 
ing, because  in  very  big  operations  I  leave  the  wounds 
quite  open." 

Mr.  Banks  would  rarely  operate  in  children,  hav- 
ing done  it  only  four  times  in  the  entire  series. 

Mr.  Kendal  Franks,^  of  Dublin,  first  operated  in 
1882.  Reports  24  cases  done  under  strict  antiseptic 
precautions. 

"  What  I  have  most  frequently  done,  is  to  clear 
the  sac  from  surrounding  parts,  then  to  open  it  and 
pass  my  finger  through  it  till  I  can  feel  the  margins  of 
the  internal  ring.  I  then  pass  the  silver  wire,  first 
through  one  pillar  of  the  ring  and  through  one  side  of 
the  sac,   then   passing  the  needle  through  the  other 


*  British    Medical   Journal,    London,    Dec.    3d,   1887,  p. 
:  202-4 


-  i85  - 

pillar  of  the  ring,  and  through  the  other  side  of  the 
sac,  I  thread  it  with  the  same  wire  and  withdraw  it. 
When  this  suture  is  fastened,  it  not  only  closes  the 
ring,  but  fixes  the  sac  between  its  pillars  in  such  a 
way  as  to  obliterate  its  cavity.  Two  wires  are  gen- 
erally used  for  this  purpose.  Below  the  sutures  the 
sac  is  excised. 

"  I  always  use  buried  sutures,  that  is,  I  endeavor 
to  sew  together  with  cat-gut  the  various  layers  of 
tissue  which  have  been  divided.  The  skin  wound  I 
bring  together  with  an  oblique  suture,  so  as  to  leave  a 
slight  pucker  at  the  upper  angle  for  drainage.  By  so 
doing  a  drainage  tube  is  seldom  required,  and  the 
first  dressing  is  allowed  to  remain  undisturbed  for  ten 
days.  I  generally  find  the  wound  perfectly  healed 
and  the  dressings  caked  and  dry. 

"  I  first  close  the  upper  part  of  the  internal  ring 
by  passing  the  silver  wire  straight  through  the  aponeu- 
rosis of  the  external  oblique  directly  over  the  internal 
ring.  The  needle  point  is,  of  course,  protected  by  a 
finger  passed  through  the  canal,  and  pressing  the  ab- 
dominal wall  forwards  at  this  place.  The  needle 
armed  with  the  wire  then  picks  up  part  of  Poupart's 
ligament,  and,  having  reached  the  finger,  is  carefully 
made  to  appear  through  the  canal,  when  the  wire  is 
caught  and  the  needle  withdrawn.  The  unarmed 
needle  now  passes  through  the  external  oblique  apo- 
neurosis, as  before,  and  at  a  point  corresponding  to 
the  other  side  of  the  ring,   passes  through  this  pillar. 


—  i86  — 

and  being  brought  out  through  the  canal,  it  is  thread- 
ed with  the  wire  and  withdrawn.  Before  this  suture 
is  twisted,  a  second  one  is  passed  at  the  lower  end  of 
the  ring  in  the  same  manner.  This  second  suture 
corresponds  generally  to  about  the  middle  point  of  the 
canal.  It  also  passes  through  the  aponeurosis  of  the 
external  oblique  immediately  in  front  of  the  lower 
part  of  the  ring.  The  third  suture,  which  is  also  gen- 
erally silver,  closes  the  external  ring.  This  I  believe 
an  immense  improvement." 

All  cases  operated  on  by  Mr.  Franks  easily  re- 
covered, and  at  time  of  report,  only  four  cases  were 
known  to  have  failed,  and  these  were  much  improved. 
"  In  competent  hands  where  every  precaution  is  taken 
against  avoidable  danger,  the  operation  is  believed  to 
be  eminently  a  safe  one." 

Mr.  Arthur  Barker,*  reports  35  cases  of  hernia 
operation,  done  at  the  University  College  Hospital, 
under  antiseptic  precautions,  with  rapid  recovery. 
His  method  consists  in  a  partial  resection  of  the  sac 
and  the  closure  of  the  canal  by  interrupted  silk 
sutures,  six  or  seven  in  number.  These  are  cut  short 
and  left  buried,  no  drainage  as  a  rule.  Dressing  anti- 
septic, salicylic  wool. 

Mr.  A.  W.  Robinson,!  of  Leeds,  England,  tabulates 
twenty-six  cases.     In  all  but  two  cases,  where  Wood's 


*British  Med.  Jour.,  London,  Dec.  3,  1S87,  p.  1204. 
fBriiish  Med.  Jour.,  Dec.  17,  1S87,  p.  1324. 


-  i87  - 
operation  was  performed,  the  sac  was  excised  after  its 
neck  had  been  ligatured,  the  canal  being  sutured,  only 
when  very  open.  Strict  Listerism  was  followed  in  every 
case.  He  recommends  ligature  of  the  sac  and  suture 
of  the  pillars  of  the  ring. 

Mr.  Chauncy  Puzey,*  of  Liverpool,  reports  twenty- 
four  cases  of  operation  by  the  open  aseptic  method. 
The  first,  in  1881.  He  emphasizes  the  dissection  of 
the  sac  and  its  ligation  as  far  up  as  possible  and  re- 
moval; suture  of  the  pillars  with  stout  chromicized 
cat-gut.  ThinksTvire  should  not  be  employed.  So 
far  as  known  there  has  been  no  failure  and  all  made 
rapid  recoveries. 

Mr.  Christopher  Heath,f  of  London,  reports  six 
operative  cases,  two  of  extroverted  bladder,  one  death. 
Advises  resection  of  sac,  with  deep  cat-gut  sutures, 
aseptically  applied. 

Mr.  C.  B.  Keetley,!  London,  contributes  an  in- 
teresting article  upon  'Hhe  radical  cure  of  hernia  by 
open  injections,"  and  in  summing  up  states,  "  I  believe 
that  a  thorough  operation  of  combined  excision,  liga- 
ture, and  suture  will  almost  certainly  effect  a  lasting 
cure.  The  dangers  are  often  considerable,  but  they 
belong  to  the  operator  rather  than  the  operation  and 
are  avoided  by  care  and   experience.      The   injection 


^British  Med.  Jour.,  London,  Dec.  17,  18S7,  p  1327 
fBritish  Med.  Jour,,  London,  May  23,  18S5,  p.  1041. 
^British  Med.  Jour.,  Dec.  3.  1887,  p.  1205. 


_  i88  — 

is  at  present  uncertain  as  to  result,  but  it  is  pre-emi- 
nently simple  and  safe." 

Mr.  F.  Treves,*  of  London,  and  Mr.  G.  A.  Wright,t 
of  Manchester,  have  presented  most  interesting  com- 
munications upon  hernia  of  the  coecum.  Mr.  Treves 
reports  two  and  Mr.  Wright  five  cases.  The  opera- 
tions are  given  in  detail  with  a  review  of  the  subject. 
The  sac  was  tied  and  resected  and  the  canal  closed 
under  antiseptic  care. 

Mr.  A.  Rabagliati,  |  of  the  Bradford  Infirmary, 
reports,  at  some  length,  the  results  of  his  experience. 
He  advocates  the  removal  of  the  sac,  stitching  the 
edges  of  the  peritoneum  by  fine  cat-gut  sutures,  as  in 
ovariotomy.  The  pillars  of  the  ring  are  closed  by  a 
second  line  of  sutures,  and  then  the  skin.  The  opera- 
tion is  done  under  antiseptic  precautions.  He  reports 
ten  successful  cases  treated  by  removal  of  the  sac. 

Mr.  John  Wood  is  to  be  commended  in  the 
changing  of  his  methods,  under  the  conviction  that 
antiseptic  measures  allow  of  better  results. 

In  the  discussion  of  Mr.  MacCormac's  address 
upon  Antiseptic  Surgery,  in  December,  i879,§  Mr. 
Wood   stated,    "in   cases   of   large  scrotal  hernia,  in 


*  British  Medical  Jeurnal,  February  19,  1887,  p.  384. 
f  British  Medical  Journal,  March  5,  18S7,  p.  506. 
X  British  Medical  Journal,  December  3,  1887,  p.  1206. 
§  Wm.    MacCorraac,  Antiseptic   Surgery,    London,  1880, 
74. 


—  189  — 

which  trusses  are  of  no  avail,  and  the  sac  is  much 
thickened,  of  great  size,  and  sometimes  presenting 
constrictions  in  its  substance  which  are  a  source  of 
great  danger  from  strangulation, — the  spray  and  gauze 
dressing,  with  the  cleanliness  and  freedom  from  con- 
tamination, putrefaction,  and  suppuration,  which  it 
affords,  has  enabled  me  to  extend  materially  the  scope 
of  benefits  to  be  derived  from  the  operation  for  the 
cure  of  hernia.  In  such  cases,  I  have  removed  the 
whole  sac,  and  sometimes  coherent  omentum,  through 
an  incision  in  the  scrotum  two  and  a  half  inches  long, 
stitched  up  the  peritoneal  orifice  with  a  continuous 
suture  of  strong  carbolized  cat-gut,  and  then  I  have 
drawn  together  the  tendinous  sides  of  the  hernial 
opening,  with  thick  silver  wire,  to  resist  the  tendency 
of  the  intestine  to  protrude  and  force  through  the  cat- 
gut suture  (which  is  too  weak  to  support  the  strain 
when  unaided  by  such  support,  and  becomes  speedily 
absorbed).  A  drainage  tube  carried  through  the  bot- 
tom of  the  wound  and  along  the  wire  enabled  me  to 
keep  the  wonnd  perfectly  clean  of  accumulation  and 
retention  of  discharges."  In  Mr.  Wood's  lectures  upon 
"Hernia  and  its  Radical  Cure,"  delivered  at  the 
Royal  College  of  Surgeons,  in  1885,  and  published  in 
the  British  Medical  Journal,  during  June,  he  writes: 
"In  the  case  of  tendon  ligature  being  used,  it  is  now 
to  be  braced  up  tightly,  tied  in  a  well-secured  sur- 
geon's knot,  cut  off  close  and  buried  in  the  wound." 
*     *     *     In  the  case  of  tendon  being  used,  a  drain- 


—  190  — 

age  tube  should  be  placed,  reaching  from  the  super- 
ficial ring  into  the  scrotal  puncture  and  the  gauze 
dressing  applied,  in  the  usual  way,  by  a  double  spica 
bandage,  with  a  piece  of  jacquenette,  through  which 
the  penis  is  passed,  placed  over  all  to  keep  off  urine 
from  the  absorbent  dressing." 

In  twenty- eight  cases  operated  on  by  the  open 
method  with  antiseptic  precautions,  the  sac  was  tied 
at  the  neck  with  separate  stout  catgut  and  removed, 
the  canal  and  rings  were  closed  by  sutures  of  kangaroo, 
or  ox  tendon,  or  wire. 

Of  the  series,  there  were  three  deaths,  but  all  from 
inflammations  of  the  lung  in  bad  subjects. 

In  the  discussion  of  femoral  hernia  he  writes: 
"  Latterly  I  have  found  the  use  of  tendon  ligature  so 
satisfactory,  that  for  this  operation  I  prefer  it  to  wire. 
The  wound  usually  closes  over  it  and  heals  by  adhesion 
at  once,  and  there  is  not  the  pain  and  inconvenience 
of  the  withdrawal  of  the  wire.  So  far  the  endurance 
of  the  tendon,  when  buried  in  the  tissues,  has  been 
long  and  satisfactory  enough  to  maintain  the  cure, 
which  has  been  watched,  noted*  in  some  cases  for  about 
two  years." 

His  method  of  suturing  is  to  transfix  the  sac  with 
a  stout  tendon  carried  through  it  by  a  needle  with 
eye  near  the  pointy  tie  on  each  side  and  cut  the  sac 
close.  In  a  deep  suture,  he  closes  the  femoral  ring 
with  the  same  tendon  and  leaves  it  as  a  buried  suture; 
uses  here  drainage  as  in  the  inguinal  variety.     He  re- 


—   191   — 

ports  to  have  operated  sixteen  times  for  strangulated 
hernia — eight  inguinal  and  eight  crural — with  attempt 
to  secure  a  cure.  "  Seven  were  done  by  ligature  of 
the  neck  by  catgut  and  entire  removal  of  the  sac,  with 
the  closure  of  the  canal  and  rings  by  wire  lacing,  and 
nine  by  the  use  of  tendon  for  all  these  purposes." 

Mr.  Wood  reports,  "one  case  of  radical  cure  of 
umbilical  hernia.  With  respect  to  the  supposed  ad- 
vantages of  the  open  method,  enabling  the  surgeon  to 
see  the  parts  on  which  he  Operates,  I  have  myself 
found  that,  after  the  first  cut  and  the  application  of 
the  sponge,  the  parts  become  so  bleared  with  blood, 
that  I  was  obliged  to  rely  mainly  upon  t-he  aid  of  the 
sense  of  touch,  before  I  ventured  to  pass  a  needle 
through  Poupart's  ligament,  the  conjoined  tendon,  or 
the  pillars  of  the  ring." 

In  conclusion,  Mr.  Wood  writes:  "It  appears 
indubitable  from  the  results  of  the  last  twenty  years' 
experience  of  the  radical  cure  of  hernia,  that  the  posi- 
tion of  those  surgical  writers,  who  have  maintained 
that  the  radical  cure  should  not  be  attempted,  except 
in  the  severest  cases,  is  untenable.  The  operation  has 
given  as  great  relief  and  exemption  from  the  minor 
troubles  and  worry  which  make  life  miserable  as  any 
operation  associated  with  prolapse,  such  as  hemor- 
rhoids, and  is  even  more  safe." 

Mr.  James  Hardie,*  of  Manchester,  England,   in 


Braithwaite's  Retrospect,  vol,  xcii,  p.  122. 


—  192  — 

a  paper  published  in  1885,  gives  the  results  of  an  ex- 
tended experience  of  operation  by  the  open  method. 
He  emphasizes  the  liability  of  the  hernia  returning  by 
a  depression  in  the  peritoneal  pouch,  and  recommends 
the  taking  of  the  sutures  through  the  neck  of  the  sac, 
so  as  to  include  quite  a  border  of  the  transversalis 
fascia.  This  with  him  is  all  the  more  important  since 
he  leaves  the  sac,  having  introduced  into  the  lower 
end  of  it  a  drainage  tube.  He  uses  wire  to  close  the 
canal. 

Mr.  Clement  Lucas,*  emphasizes  the  removal  of 
the  sac  as  of  itself  always  to  be  considered  a  source  of 
danger.  "  To  rid  the  patient  of  this  abnormal,  over- 
strained, ill-nourished,  not  only  useless,  but  absolutely 
injurious  piece  of  tissue,  should  be  the  aim  of  every 
surgeon  when  called  upon  to  operate  for  strangulation, 
after  reducing  the  bowel.  It  is  probable  the  only 
operation  for  radical  cure  that  will  stand  the  test  of 
time.  I  regard  no  operation  for  femoral  hernia  com- 
plete, till  the  sac  has  been  excised,  even  although  the 
bowel  may  have  been  reduced  before  the  opening  of 
the  sac.  The  same  may  be  said  of  acquired  congenital 
hernia.  The  congenital  inguinal  presents  especial 
difficulties,  as  the  whole  sac  cannot  be  excised  without 
sacrificing  the  testicle;  but  I  usually  excise  the 
funicular  portion,  and  rigid  antisepsis  is  here  advis- 
able."    Dr.  Lucas  also  reports  two  very  interesting 


♦British  Med.  Jour.,  Oct.,  1885. 


—  193  -- 
cases  of  cure  of  large  umbilical  hernia,  by  the  use  of 
deep  buried  cat  gut  sutures;  both  patients   made  easy 
recoveries." 

Mr.  Stokes,  of  Dublin,  uses  the  open  method  of 
operation.  He  freely  opens  the  sac,  stitches  up  the 
neck,  and  draws  together  the  canal  and  pillars  of  the 
ring  with  chromicized  cat-gut,  carbolized  silk,  or  wire, 
but  does  not  remove  the  sac.  This  he  considers  risky 
and  unsurgical. 

Mr.  Alexander,  of  Liverpool,  modifies  the  open 
dissection,  by  tying  the  neck  of  the  sac,  as  deeply  as 
possible,  and  divides  below  the  suture,  but  does  not 
disturb  the  sac,  or  suture  the  rings.  He  reports 
thirty  cases  performed  for  the  radical  cure  without  a 
death. 

Sir  Wm.  MacCormac  is  reported  to  have  adopted 
this  method. 

Prof.  Buchanan,  of  Glasgow,  in  congenital  hernia 
slits  up  the  sac  longitudinally  on  each  side  of  the 
cord.  The  anterior  part  is  divided  transversely,  and 
sutured  into  the  ring  as  a  plug;  the  lower  part  is 
turned  down  to  complete  the  tunica  vaginalis. 

Mr.  C.  B.  Ball,*  reports  his  method  of  cure  of 
hernia  by -torsion  of  the  sac.  He  emphasizes  the  com- 
plete separation  of  the  sac  from  the  structures  of  the 
cord,  a  matter  sometimes  of  no  small  difficulty.  "  The 
peritoneum  loosened  a  little  about  the  ring,  the  empty 


*British  Med.  Jour.,  Dec.  lo,  1887,  p.  1272. 

14  DD 


—  194  — 

sac  is  firmly  held  at  its  neck  by  forceps,  and  gradu- 
ally twisted,  generally  four  or  five  turns  are  sufficient, 
but  the  torsion  should  be  continued,  until  it  is  felt  to 
be  quite  tight  or  rupture  seems  imminent.  Thus  held, 
the  twisted  neck  is  tied  with  cat  gut  as  high  as  pos- 
sible and  the  ends  cut  off  short."  "Two  sutures  of 
strong  aseptic  silk  are  now  passed  through  the  skin, 
at  a  distance  of  about  an  inch  from  the  outer  margin 
of  the  wound,  through  the  outer  pillar  of  the  ring, 
through  the  twisted  sac  in  front  of  the  cat-gut  suture, 
and  then  through  the  inner  pillar  of  the  ring  and  skin 
upon  the  inside.  As  these  sutures  effectually  prevent 
the  sac  from  untwisting,  it  may  now  be  cut  off  in  front 
of  them,  and  a  cat-gut  drain  is  brought  out,  through 
a  separate  opening,  at  the  back  of  the  scrotum,  and 
the  two  sutures  closed  over  lead  plates,  which  lie  at 
right  angles  to  the  wound."  Superficial  sutures  are 
applied  if  required  and  a  dry  dressing  is  held  by  a 
fixed  silicate  of  potash  bandage. 

Post  mortem  testing  shows  the  peritoneum  to  be 
thrown  into  spiral  folds  radiating  in  all  directions 
from  the  ring  and  extending  about  four  inches. 

Mr.  Ball  thinks  the  twisted  sac  thus  transfixed 
makes  a  slight  projection,  rather  than  depression, 
within  the  abdominal  cavity.  He  reports  twenty-two 
cases  of  his  own,  beside  a  number  under  his  observa- 
tion done  by  other  surgeons.  All  recovered.  All 
were  performed  within  four  years.  Three  obliged  to 
wear  a  truss  from  a  weakening  of  the  ring.      Dr.  Ball 


—  195  — 
deprecates  the  wearing  of  a  truss,  since  the  pressure 
of  the  pad  tends  to  produce  absorption  of  the  plastic 
effusion  into  the  canal,  upon  which  the  success  of   the 
operation  so  largely  depends. 

Mr.  W.  P.  Stoker,*  of  Dublin,  advocates  the  open 
dissection  method,  has  adopted  the  plan  of  Mr.  Ball 
of  twisting  the  neck  of  the  sac,  and  suturing  under 
aseptic  precautions.  He  argues,  as  Mr.  Ball,  that 
the  lymph  effusion  is  the  factor  sought,  that  sutures 
serve  but  a  temporary  purpose,  and  their  chief  end  is 
to  secure  an  abundant  exudation. 

Mr.  John  Poland,!  of  Guy's  Hospital,  London, 
in  a  paper  upon  the  treatment  of  the  sac  in  strangu- 
lated hernia,  reviews  the  different  methods  of  treat- 
ment and  commends  the  ligature  of  the  neck  and  ex- 
cision. By  it  the  peritonum  is  effectively  closed  from 
hemorrhage  and  septic  infection  and  it  holds  out  a 
great  hope  of  permanent  cure,  not  only  in  restoring 
the  patient  to  a  more  normal  condition  by  removing 
a  more  or  less  open  tract  along  which  a  portion  of  in- 
testine might  again  descend,  this  tract  being  in  fact 
composed  of  morbid  and  useless  tissues,  also  in  pro- 
ducing a  radiating  puckering  of  the  peritoneum  around 
the  hernial  orifice  and  closing  the  orifice  itself  by 
dense  cicatricial  tissue,  and  thereby  tending  to  prevent 
yielding  again  at  this  spot. 


*  Practitioner,  Nov.  1887,  p.  355. 

f  Brit.  Med.  Jnl.,  Dec.  3,  1887,  P-  1201. 


—  196  — 

We  do  away  with  an  indurated  thickened  mass, 
which  often  exists  where  the  sac  has  been  allowed  to 
remain  untouched.  *  *  In  cases  where  the  open- 
ing is  large,  the  pillars  of  the  ring  may  be  brought  to- 
gether by  sutures,  without  adding  to  the  risk  of  the 
operation.  *  *  Ligature  without  excision  has  no 
advantage  over  ligature  with  excision." 

Mr.  F.  T.  Heustonf  contributed  a  most  mterest- 
ing  paper  to  the  surgical  section  of  the  British  Med- 
ical Association,  upon  the  radical  cure  of  femoral 
hernia,  and  reports  an  illustrative  case  in  a  woman  of 
seventy.  The  cure  was  easy  and  complete,  although 
the  sac,  besides  a  loop  of  intestine  contained  a  gan- 
grenous Fallopian  tube  and  the  ovary;  both  were  re- 
moved. The  sac  was  tightly  twisted  and  transfixed 
with  chromici/ied  gut,  and  excised.  The  canal  and 
fascia  were  closed  by  buried  sutures.  Mr.  Heuston 
remarks,  "  it  is  sufficiently  rare  to  find  the  Fallopian 
tube  and  ovary  within  hernial  sacs,  to  allow  another 
case  being  recorded;  as  I  find  in  187 1,  there  were 
only  thirty-eight  cases  recorded,  namely  twenty-seven 
inguinal,  nine  femoral,  one  sciatic,  and  one  obturator. 
Of  these,  however,  seventeen  were  congenital,  all  of 
which  were  inguinal  and  the  ovary  alone  was  usually 
in  the  acquired  herniae,  while  only  five  of  the  cases 
contained  intestine."  Besides  the  advantage  derived 
from  the  removal  of  the  sac  and  closing  the   periton- 


t  Brit.  Med.  Jnl.,  Dec.  3,  1887. 


—  197  — 
eum  by  twisting  the  neck,  Mr.  Heuston  emphasizes 
the  importance  of  closure  of  the  tissues  "  in  proper 
and  consecutive  order  by  hidden  sutures,  the  most 
important  being  the  first  applied,  namely,  uniting  the 
fascia  transversalis  forming  the  anterior  wall  of  the 
femoral  canal  to  the  fascia  iliaci  and  anti-psoas  layer 
of  the  pubic  portion  of  the  fascia  lata  behind  and 
within."  He  uses  chromicized  catgut  throughout 
the  operation  which  allows  of  immediate  union  and 
does  not  require  subsequent  removal. 

In  the  discussion  of  Mr.  Heuston's  paper,  Mr. 
Walsham  remarked,  "that  he  thoroughly  advocated 
Mr.  Banks'  method.  He  uses  "  kangaroo  tail  tendon 
and  believed  that  when  it  was  securely  knotted,  it  was 
a  most  reliable  ligature,  and  preferable  to  both  wire 
and  silk." 

Dr.  Ward  Cousins  said  "  that  the  surgery  of 
hernia  had  made  recently  most  rapid  advance,  especi- 
ally in  the  direction  of  the  radical  cure  in  young 
children.  He  had  operated  on  more  than  fifty  cases, 
and  thirty  of  these  were  cures;  the  rest  had  been  done 
too  recently  to  express  an  opinion.  He  removes  the 
sac  after  ligature  at  the  neck  and  closes  the  edges 
with  a  continuous  suture.  He  advocates  silk  or  wire 
as  more  trustworthy  than  catgut. 

No  one  of  the  recent  contributions  upon  the  cure 
of  hernia  has  deservedly  attracted  a  larger  share  of 
attention  than  the  paper  of  Mr.  Wm.  Macewen,  of 
Glasgow,    published    in   the    "  Annals    of    Surgery," 


August,  1886.  This  was  supplemented  by  a  further 
contribution  upon  the  subject  to  the  British  Medical 
Association  and  published  in  the  Journal*  Mr.  Mac- 
ewen  states,  "  that  he  was  led  up  to  the  adoption  of 
his  present  method  by  his  studies  upon,  the  various 
methods  of  the  treatment  of  the  sac,  and,  believing 
that  there  was  generally  left  a  depressed  pouch,  or 
funnel-shaped  puckering  of  the  peritoneum  at  the  in- 
ternal ring,  which  receives  the  wave  of  impulse  of  the 
liquid  movement  of  the  intestine,  he  sought  in  the 
device  which  characterizes  his  method,  to  reinforce 
the  weak  spot  by  a  new  use  of  the  sac.  The  steps  of 
the  operation  are  given  as  follows: 

"  I.  Free  and  elevate  the  distal  extremity  of  the 
sac,  preserving  along  with  it  any  adipose  tissue  that 
may  be  adherent  to  it;  when  this  is  done  pull  down 
the  sac,  and  while  maintaining  tension  upon  it,  intro- 
duce the  index  finger  into  the  inguinal  canal,  separat- 
ing the  sac  from  the  cord  and  from  the  parietes  of 
the  canal. 

2.  Insert  the  index  finger  outside  the  sac  till  it 
reaches  the  internal  ring;  there  separate  with  its  tip 
the  peritoneum  for  about  half  an  inch  round  the  whole 
abdominal  aspects  of  the  circumference  of  the  ring. 

3.  A  stitch  is  secured  firmly  to  the  distal  ex- 
tremity of  the  sac.  The  end  of  the  thread  is  then 
passed  in  a  proximal  direction  several  times  through 


*  British  Medical  Journal,  December  10,  1887,  p.  1263-71 


—    199  — 

the  sac,  so  that  when  pulled  upon,  the  sac  becomes 
folded  upon  itself  like  a  curtain.  The  free  end  of  this 
stitch,  threaded  on  a  hernia  needle,  is  introduced 
through  the  canal  to  the  abdominal  aspect  of  the 
fascia  transversalis,  and  there  penetrates  the  anterior 
abdominal  wall,  about  an  inch  above  the  upper  border 
of  the  internal  ring.  The  wound  in  the  skin  is  pulled 
upwards,  so  as  to  allow  the  point  of  the  needle  to 
project  through  the  abdominal  muscles,  without  pene- 
trating the  skin.  The  thread  is  relieved  from  the 
extremity  of  the  needle,  when  the  latter  is  withdrawn. 
The  thread  is  pulled  through  the  abdominal  wall,  and 
when  traction  is  made  upon  it,  the  sac,  wrinkling  upon 
itself,  is  thrown  into  a  series  of  folds,  its  distal  ex- 
tremity being  drawn  furthest  backward  and  up- 
ward. An  assistant  maintains  traction  upon  the  stitch 
until  the  introduction  of  the  sutures  into  the  inguinal 
canal,  and  when  this  is  completed,  the  end  of  the 
stitch  is  secured  by  introducing  its  free  extremity 
several  times  through  the  superficial  layers  of  the  ex- 
ternal oblique  muscles.  A  pad  of  peritoneum  is  thus 
placed  upon  the  abdominal  side  of  the  internal  open- 
ing, where,  owing  to  the  abdominal  aspect  of  the  cir- 
cumference of  the  internal  ring  having  been  refreshed, 
new  adhesions  may  form. 

The  sac  having  been  returned  into  the  abdomen 
and  secured  to  the  abdominal  circumference  of  the 
ring,  this  aperture  is  closed  in  front  of  it  in  the  follow- 
ing manner:     The  finger  is  introduced  into  the  canal. 


200    

and  lies  between  the  inner  and  lower  borders  of  the 
internal  ring,  in  front  of  and  above  the  cord.  It 
makes  out  the  position  of  the  epigastric  artery,  so  as 
to  avoid  it.  The  threaded  hernia  needle  is  then  in- 
troduced, and,  guided  by  the  index  finger,  is  made  to 
penetrate  the  conjoint  tendon  in  two  places;  first,  from 
without  inwards,  near  the  lower  border  of  the  conjoint 
tendon;  secondly,  from  within  outwards,  as  high  up  as 
possible  on  the  inner  aspects  of  the  canal.  This 
double  penetration  of  the  conjoint  tendon  is  accom- 
plished by  a  single  screw-like  turn  of  the  instrument. 
One  single  thread  is  then  withdrawn  from  the  point  of 
the  needle  by  the  index  finger,  and  when  that  is  ac- 
complished, the  needle,  along  with  the  other  extremity 
of  the  thread,  is  removed.  The  conjoint  tendon  is 
therefore  penetrated  twice  by  this  thread,  and  a  loop 
left  on  its  abdominal  aspect.  Secondly,  the  other 
hernia  needle,  threaded  with  the  portion  of  the  stitch 
which  comes  from  the  lower  border  of  the  conjoint 
tendon,  guided  by  the  index  finger  in  the  inguinal 
canal,  is  introduced  from  within  outwards,  through 
Poupart's  ligament,  which  it  penetrates  at  a  point  on  a 
level  with  the  lower  stitch  in  the  conjoint  tendon. 
The  needle  is  then  completely  freed  from  the  thread 
and  withdrawn. 

Thirdly,  the  needle  is  now  threaded  with  that 
portion  of  the  catgut  which  protrudes  from  the  upper 
border  of  the  conjoint  tendon,  and  is  introduced  from 
within  outwards  through  the  transversalis  and  internal 


20I     

oblique  muscles,  and  the  aponeurosis  of  the  external 
oblique  at  a  level  corresponding  with  that  of  the  upper 
stitch  in  the  conjoint  tendon.  It  is  then  quite  freed 
from  the  thread  and  withdrawn.  There  are  now  two 
free  ends  of  the  suture  on  the  outer  surface  of  the  ex- 
ternal oblique,  and  these  are  continuous  with  the  loop 
on  the  abdominal  aspect  of  the  conjoint  tendon.  To 
complete  the  suture,  the  two  free  ends  are  drawn 
tightly  together  and  tied  in  a  reef-knot.  This  unites 
firmly  the  internal  ring.  The  same  stitch  may  be  re- 
peated lower  down  the  canal  if  thought  desirable. 
The  pillars  of  the  external  ring  may  likewise  be 
brought  together.  In  order  to  avoid  compression  of 
the  cord,  which  might  lead  to  serious  embarassment 
and  sloughing,  or  ultimate  atrophy  of  the  testicle,  it 
ought  to  be  examined  before  tightening  the  stitch. 
The  cord  ought  to  lie  behind  and  below  the  sutures, 
and  be  freely  movable  in  the  canal.  It  is  advisable  to 
introduce  all  the  necessary  sutures  before  tightening 
any  of  them.  When  this  is  done,  they  might  all  be 
experimentally  drawn  tight,  and  maintained  so  while 
the  operator's  finger  is  introduced  into  the  canal  to 
ascertain  the  result.  If  satisfactory,  they  are  then 
tied,  beginning  with  the  one  at  the  internal  ring  and 
taking  up  in  order  any  others  which  may  have  been 
introduced.  In  the  great  majority  of  cases  the  stitch 
in  the  internal  ring  is  all  that  is  required.  During  the 
operation  the  skin  is  retracted  from  side  to  side,  to 
bring  the  parts  into  view,  and  to  enable  the  stitches  to 


202    

be  fixed  subcutaneously.  When  the  retraction  is  re- 
lieved, the  skin  falls  into  its  normal  position,  the 
wound  being  opposite  to  the  external  ring.  The 
operation  is  therefore  partly  subcutaneous.  When 
the  canal  has  been  brought  together,  a  decalcified 
chicken-bone  drainage  tube  is  placed  with  its  one  ex- 
tremity next  the  external  ring,  the  other  projecting 
just  beyond  the  lower  border  of  the  external  wound. 
A  few  chromic  gut  sutures  are  then  introduced  along 
the  line  of  the  skin  incision.  The  wound  is  dusted 
with  iodoform,  also  the  interstices  of  the  scrotum,  and 
its  junction  with  the  thigh.  A  sublimated  wool  pad 
is  applied,  held  in  position  by  an  aseptic  bandage."* 

Mr.  Macewen  tabulates  eighty-one  cases,  without 
a  death,  and  with  a  firm  occlusion  obtained  before 
leaving  the  ward.  The  material  used  for  sutures,  as 
by  far  the  most  serviceable,  is  considered  to  be  cat- 
gut prepared  so  as  to  resist  the  action  of  the  tissues 
from  two  to  three  weeks.  The  use  of  decalcified 
chicken-bone  drainage  tubes  are  considered  by  Mr. 
Macewen  as  admirably  suited  for  the  operation. 

At  the  meeting  of  the  Congress  of  Italian  Sur- 
geons, March,  1888,  Prof.  Bassini  described  a  new 
method  of  cure  in  inguinal  hernia  which  he  had  suc- 
cessfully practiced  in  one  hundred  and  two  cases. 
The  purpose  of  his  method  is  to  restore  the  obliquity 
of  the  canal.     He  lays  open  the  canal  to  the  internal 


*British  Medical  Jour.,  Dec.  10,  1867,  p.  1264. 


—    203    — 

ring.  The  sac  is  separated,  drawn  down,  ligated,  and 
resected.  The  closed  peritoneum  is  returned,  the 
spermatic  cord  is  pushed  aside,  and  the  posterior 
margin  of  Poupart's  Hgament  exposed.  The  deeper 
layer  is  dissected  in  such  a  manner  that  it  can  be 
brought  in  close  apposition  to  the  posterior  margin  of 
Poupart's  ligament. 

From  the  ileo-pubic  tubercle,  the  canal  is  united, 
posteriorly,  from  five  to  seven  centimeters  to  the  en- 
trance of  the  cord  into  the  abdominal  cavity.  The 
cord  is  then  replaced,  and  the  aponeurosis  of  the  ex- 
ternal oblique  sutured,  only  opening  sufficient  for  the 
cord  without  compression  being  left.  The  wound  is 
closed  with  drainage.  The  advantages  claimed  for 
the  operation  are  that  it  restores  the  inguinal  canal  to 
its  natural  condition.  The  internal  opening  and  the 
posterior  wall  are  new-formed,  the  external  ring  nar- 
rowed. This  restores  the  canal  to  its  normal  oblique 
position.  The  posterior  wall,  being  composed  of 
muscle  and  aponeurosis,  is  permanent  and  will  not 
disappear  like  the  cicatricial  plug  in  Wood's  operation. 
In  the  author's  102  cases,  95  were  reducible  and  seven 
strangulated  hernias;  in  98,  the  hernia  was  complete 
oblique,  and  in  four  complete  direct.  The  conclu- 
sions are  formulated: 

"i.     The  method  is  absolutely  without  danger. 

2.  It  effects  a  radical  cure  in  a  short  space  of 
time. 

3.  It  obviates  the  necessity  of  wearing  a  truss, 
as  after  the  other  operative  procedures." 


204    — 

Andaregg*  has  published  a  thoughtful  article 
upon  the  radical  cure  of  hernia  by  the  removal  of  the 
sac  and  closure  of  the  canal.  He  gives  a  long  list  of 
cases  in  detail  where  the  results  have  been  carefully- 
noted.  Of  a  list  of  55  patients,  where  the  radical 
operation  was  performed,  38  are  reported  cured,  free 
from  any  return.     In  71  cases  there  were  11  deaths. 

Leisrinkf  has  reported  188  cases  of  strangulated 
hernia  operated  on,  and  in  the  list,  from  all  causes, 
there  were  ;^;^  deaths.  He  thinks  the  return  of  the 
hernia  is  less  likely  to  follow  the  radical  operation 
when  done  after  strangulation,  than  when  performed 
in  reducible  cases.  His  paper,  as  well  as  that  of 
Andaregg,  contains  much  of  interest,  however,  the 
data  are  quite  too  imperfect  from  which  to  draw  con- 
clusions of  exceptional  value. 

Riesel  J  advocates  the  division  of  the  anterior 
wall  of  the  canal  as  far  as  the  internal  ring.  He  nar- 
rows the  canal  by  removing  a  portion  of  the  anterior 
wall  and  unites  by  transverse  sutures  from  above 
downwards,  so  as  to  close  the  canal  as  much  as  possi- 
ble, in  the  belief  that,  in  this  way,  he  reforms  and 
restores  the  obliquity  of    the  opening.      Usually  he 


*  Die  Moderne  Radicaloparation  der  Unterleibs  briiche, 
1883. 

f  "  Die  Radicaloperation  der  Hernien,"  Deutsch.  Zeit- 
schrift  f.  Chirurg.,  1886. 

X  Otto  Riesel,  "  Deutsche  med.  Wochenschrift,"  Berlin, 
1887,  pp.  449-467. 


—    205    — 

ties  the  sac  high  up  and  leaves  the  empty  sac  below, 
believing  that  it  gives  a  farther  security  and  protection 
from  return.  The  superficial  wound  he  unites  over 
the  deeper  layer. 

Riesel  claims  by  his  method  of  splitting  the  canal, 
he  can  dissect  and  free  the  sac  to  its  very  base,  and, 
in  this  way,  obliterate  any  pouching  of  the  peritoneum. 

"  In  Sweden,  an  *  improved '  operation  for  the 
radical  cure  of  hernia  has,  for  sometime  past,  been 
practiced  by  Drs.  Svensson  and  Erdmann,  Surgeons 
to  the  Sabbatsberg  Hospital,  at  Stockholm.  A  liga- 
ture is  applied  to  the  neck  of  the  hernia,  and  the  sac 
is  cut  off  below  the  ligature,  the  contents  being  pre- 
viously examined  by  means  of  an  incision  into  the  sac, 
and  returned;  or  if  only  omental,  excised,  together 
with  the  sac.  In  congenital  hernia,  the  upper  part  of 
the  sac  only  is  removed,  and  where  the  large  bowel  is 
included  in  the  hernia  and  adherent  to  the  sac  wall, 
this,  after  being  separated  from  the  surrounding 
tissues,  is  returned  together  with  the  large  intestine, 
and  the  rents  of  Poupart's  ligament  united  by  sutures. 

The  dressing  employed  is  iodoform  and  boracic 
acid,  the  wounds  being  washed  with  sublimate  solu- 
tion. Since  this  has  been  substituted  for  carbolic 
gauze,  abscesses,  which  used  to  occur  frequently,  have 
become  rare.  Of  the  48  cases  thus  operated  on,  none 
of  which  were  selected,  38  were  permanently  cured; 
at  least,  no  return  of  the  hernia  occurred  within  six 
months;  and   in  the  cases  where  a  return  did   take 


—    2o6   

place,  which  amounted  to  20  per  cent.,  the  condition 
was  very  much  less  painful  and  distressing  than  it  had 
been  previous  to  the  operation. 

Sabbatsberg  Hospital  has  now  been  opened  six 
years  and  a  half,  and  during  that  time  300  cases  of 
hernia  have  been  admitted,  about  200  of  these  being 
operated  on  with  a  knife,  a  milder  procedure,  consist- 
ing of  alcoholic  injections,  being  employed  in  most  of 
the  earlier  cases.  Not  a  single  case  proved  fatal, 
though  some  of  the  herniae  were  very  large,  some 
reaching  within  three  or  four  inches  of  the  knee."* 

THE    CURE    OF    HERNIA  BY  THE    OPEN   WOUND    METHOD 
IN     AMERICA. 

It  is  only  very  recently  that  the  operation  for  the 
cure  of  hernia  has  been  looked  upon  favorably  by 
surgeons  of  the  United  States. 

In  1858  Dr.  Gross,  of  Philadelphia,  cut  down 
upon,  and  brought  together  the  rings  with  silver  wire 
in  two  cases  followed  by  cure.  In  1878  Dr.  D.  W. 
Cheever  reported,  "  I  tried  cat-gut  for  a  radical  cure 
of  hernia,  but  it  was  speedily  absorbed  and  failed." 

In  August,  1886,  Dr.  John  B.  Hamilton,  Surgeon 
Gen.  U.  S.  Marine  Hospital  Service,  read  before  the 
Chicago  Medical  Society,  a  very  valuable  lecture  upon 
the  Radical  Cure  of  Inguinal  Hernia. f     After  a  care- 


*  (Medical  and  Surgical  Reporter,  Philadelphia,  1886,  ix., 
115.) 

f  Jour.  Amer.  Med.  Asso  ,  Sept.  4,  1886. 


207    — 

ful  review  of  the  open  method  as  performed  with  anti- 
septic care,  Dr.  Hamilton  writes: 

"As  no  logical  reason  can  be  given  for  a  failure 
to  accept  the  view  that  there  has  been  an  advance,  I 
perhaps  need  not  say,  •  that  I  favor  in  all  cases,  afford- 
ing even  a  reasonable  prospect  of  cure,  an  operatio7i  there- 
for, and  that  all  cases  whatsoever  of  bubonocele  should 
be  operated  upon'  " 

Dr.  E.  H.  Bradford,*  of  Boston,  to  the  Society  of 
Medical  Improvement,  March  14,  1887,  reported  a 
case  of  radical  cure  of  hernia  operated  upon  recently 
by  Macewen's  method. 

Dr.  T.  J.  McGillicuddy,f  reports  a  case  of  radical 
cure  of  a  strangulated  oblique  inguinal  hernia  with 
ligature,  removal  of  the  sac  and  recovery.  He  ends 
his  paper  with  a  plea  for  the  removal  of  the  sac  and 
closing  with  deep  firm  sutures. 

In  an  interesting  paper  by  Dr.  Thomas  H.  Burch- 
ard,|  of  New  York,  upon  the  modern  treatment  of 
strangulated  hernia,  the  subject  of  operative  measures 
is  carefully  reviewed.  As  is  well  known,  he  is  an  ad- 
vocate for  early  operation.  He  prefers  dissection  of 
the  sac,  suture  of  the  base,  and  return  of  the  stump; 
then  a  careful  coaptation  of  the  rings  and  canal  by 
deep  sutures  of  cat-gut.      He   reports   one   case   by 


*Boston  Med.  and  Surg.  Jour.,  April  21,  1887,  p.  375. 
fNew  York  Med.  Jour.,  Dec.  31,  1887,  p.  737. 
:|:New  York  Med.  Jour.,  Jan.  21,   1888,  p.  6-15. 


—    208    — 

Macewen's  method.  **  This  is  the  only  case  in  which 
suppuration  of  any  material  consequence  occurred. 
Had  I  ever  seen  the  operation  performed,  or  had  I 
previous  experience  with  it,  I  might  have  secured 
better  result.  As  it  is,  the  cicatrix  is  very  painful,  and 
a  hardened  mass,  at  the  site  of  the  internal  ring,  will 
scarcely  tolerate  the  slightest  pressure." 

"  I  have  operated  in  nine  cases  of  strangulated 
hernia  in  which  I  have  been  enabled  to  carry  out  the 
operation  in  all  its  details.  Eight  recovered,  one 
developed  delirium  tremens  and  died  the  fourth  day." 

Dr.  Robert  Weir,*  of  New  York,  treats,  at  some 
length,  the  subject  of  the  disposition  of  the  sac  after 
operation.  He  emphasizes  the  great  advances  made 
in  modern  surgery,  in  the  treatment  of  strangulated 
hernia,  contrasts  the  various  methods  of  treatment  of 
the  sac,  and  thinks,  in  some  cases,  the  Macewen 
method  advisable.  This  he  has  performed  eight 
times.  The  preference  will  be  between  this  method 
and  ligation  and  excision  of  the  sac.  He  prefers  the 
use  of  heavy  cat-gut.  Dr.  Weir  accepts  the  radical 
operation  as  a  marked  improvement  in  the  treatment 
of  hernia,  whether  free  or  strangulated,  although  he 
does  not  consider  the  operation  perfected. 

Dr.  Charles  McBurney,f  of  New  York,  in  a  contri- 
bution upon   the   radical  cure  of  hernia  by  the  open 


*N.  Y.  Med.  Jour.,  Jan.  21,  1888,  p.  65-8. 
fN.  Y.  Med.  Jour.,  Jan.  21,  1888,  p.  58-61. 


209    — 

wound  method,  reports  twenty-seven  cases  where  he 
has  operated  in  non-strangulated  hernias  since  1882, 
by  various  methods.  One  patient  died  of  shock  a  few 
hours  after  operation,  but  he  was  a  hard  drinker.  All 
the  other  cases  made  easy  recoveries.  He  considers 
hemorrhage  and  sepsis  the  great  dangers,  both  pre- 
ventable. ''  The  method  of  closing  the  sac  by  liga- 
ture is  clearly  better  than  the  other  plan  of  cutting  it 
off  and  closing  the  communication  with  the  peritoneal 
cavity  by  suture.  It  is  more  rapid,  it  is  more  even, 
and  the  great  danger  is  absolutely  avoided  of  having 
the  intestines  suddenly  forced  out  through  the  wound 
by  an  unexpected  effort  of  coughing  or  vomiting. 
Two  other  methods  of  shutting  off  the  sac  remain  to 
be  referred  to,  that  of  torsion  and  of  Macewen."  *  *  * 
*'  That  this  method  obliterates  the  sac  is  evident  from 
the  brilliant  results  obtained  by  Macewen  in  a  large 
number  of  cases,  but  I  question  its  superiority  in  or- 
dinary cases  over  the  carefully  applied  ligature,  and 
in  larger  hernia  it  makes  no  provision  at  all  against 
the  great  laxity  of  peritoneum,  which  exists  in  all  such 
cases  around  the  internal  orifice  of  the  canal."  Dr. 
McBurney  enters  into  an  argument  of  some  length  to 
show  why  he  considers  suturing  of  the  canal  a  useless 
undertaking,  based  upon  the  conditions  and  relations 
of  the  tendinous  structures  which  make  up  the  canal. 
Because  of  this,  he  has  abandoned  closure  and  treats 
by  the  open  method  in  a  manner  peculiar  to  himself. 
"  Six  or  eight  interrupted  stitches,  on   the  upper  side 

15   DD 


of  the  wound,  bind  into  one  thick  edge  the  skin,  the 
external  abdominal  aponeurosis,  including  the  inner 
pillar  of  the  ring,  and  the  transversalis  and  internal 
oblique  muscles  and  conjoined  tendon.  As  many- 
more  stitches,  on  the  lower  side  of  the  wound,  bind 
together  the  skin  and  Poupart's  ligament,  including 
below  the  outer  pillar  of  the  ring."  This  ensures  an 
open  canal,  which  must  slowly  fill  by  granulation. 
Iodoform  gauze  is  packed  into  the  wound  and  com- 
pletes the  dressing.  Dr.  McBurney  thinks  he  obtains 
double  advantage — an  antiseptic  wound  without  drain- 
age, and  a  firm  closure  of  the  walls  of  the  canal  by 
strong  cicatricial  tissue. 

Dr.  Dudley  P.  Allen,*  of  Cleveland,  has  contrib- 
uted an  interesting  article  upon  the  radical  cure  of 
hernia  in  which  he  advocates  the  open  wound  method 
under  strict  antisepsis.  His  method  is  extirpation  of 
the  sac  after  suturing  at  the  base  with  catgut  and 
uniting  the  pillars  of  the  ring  with  interrupted  silk 
sutures,  one  end  left  long;  a  drainage  tube  is  inserted 
to  just  outside  the  united  pillars,  and  superficial  in- 
terrupted stitches  close  the  wound.  An  aseptic  state 
is  maintained  for  a  week,  when  suppuration  is  allowed 
and  the  silk  sutures  through  the  ring  removed  as  they 
become  loose.  In  this  way  he  thinks  the  plastic  re- 
pair is  more  firm  and  resisting,  than  in  primary  union. 
Reports  one  case  operated  on  at  two  years  of  age. 
His  first  operation  was  in  1885. 

*  Medical  Record,  N.  Y.,  Aug.  11,  '88,  pp.  141-3. 


211     

At  the  meeting  of  the  Suffolk  District  Medical 
Society  Drs.  G.  H.  Monks  and  R.  Whitman,  of  Boston, 
each  reported  one  case  of  cure  of  hernia  by  Macewen's 
method."^  There  followed  a  long  discussion  by  a  con- 
siderable number  of  surgeons  who  had  operated  for 
the  cure  of  hernia,  and  the  general  opinion  expressed 
was  in  favor  of  a  radical  disposition  of  the  sac  and 
closure  of  the  canal  with  animal  suture. 

Dr.  H.  L.  Burrell,f  of  Boston,  reports  eight  cases 
of  radical  operation  for  the  cure  of  hernia.  In  the 
manipulation  of  the  sac,  he  has  found  advantage  in 
distending  it  with  a  ball  of  iodoform  gauze.  He 
closes  the  canal  with  two  or  three  interrupted  stitches, 
silk,  or  cat  gut,  and  does  not  use  drainage.  Closure 
of  the  wound  is  effected  by  continuous  cat-gut  suture. 
Dr.  Burrell  makes  emphasis  upon  aseptic  conditions, 
and  especially  in  the  case  of  the  superimposed  dress- 
ings; six  gauze  pads  6x8  in.  held  in  place  by  careful 
bandaging,  then  a  piece  of  macintosh  with  hole  to  ad- 
mit the  penis  and  over  this  sterilized  sheet  wadding. 
A  cravat  gauze  bandage,  six  inches  wide,  long  enough 
to  form  a  double  spica  bandage,  holds  this  in  place. 
Over  this  is  another  piece  of  mackintosh,  through 
which  the  penis  protrudes,  held  m  place  by  safety 
pins. 

In  the  same  journal.  Dr.  Hayward  W.  Gushing,  of 


*  Boston  Med.  and  Surg.  Jnl.,  Dec.  6,  '88. 
t  Boston  Med.  and  Surg.  Jnl.,  March  22,  '8 


Boston,  reports  a  case  of  femoral  hernia  in  a  boy  of 
twelve,  where  he  operated  by  adapting  the  method  of 
Prof.  Macewen  to  the  conditions  found.  After  free- 
ing the  sac,  which,  in  this  instance,  was  attended  with 
difficulty,  he  replaced  and  retained  it  within  the  ring 
as  advised  by  Macewen.  Dr.  Gushing  then  closed 
the  crural  ring  by  suturing  Poupart's  ligament  with  a 
"quilted  suture,"  to  the  pubic  portion  of  the  fascia 
lata  and  the  fascia  covering  the  pectineus  muscle,  the 
femoral  vein  being  protected  by  a  retractor.  The 
margins  of  the  saphenous  opening  are  then  closed  by 
overlapping  after  Macewen's-  method  in  inguinal 
hernia.     The  result  was  excellent. 

Dr.  L.  S.  Pilcher,  of  Brooklyn,  has  reported  to 
me  two  cases  of  strangulated  hernia,  where  he  oper- 
ated with  complete  cure,  in  patients  each  eighty-three 
years  of  age. 

The  first,  a  male,  the  hernia  inguinal,  had  existed 
many  years.  The  sac  was  double,  was  dissected,  tied 
high  up  and  cut  off.  The  wound  filled  with  iodoform 
gauze  and  allowed  to  granulate;  recovery  slow.  The 
second  a  female;  old  femoral  hernia,  the  adherent 
omentum  was  ligatured  and  resected,  also  the  sac, 
the  stump  of  which  was  pushed  within  the  internal 
ring  and  "  the  tissues  of  the  canal  closely  sewed  over 
and  over  with  cat-gut,  superficial  sutures.  Healing 
by  first  intention  throughout  whole  extent  of  wound 
with  quite  an  appreciable  plastic  exudate  in  site  of 
canal." 


—    213   — 

Dr.  John  H.  Mackie,  of  New  Bedford,  writes  me 
that  he  "  has  operated  nearly  two  hundred  times  in 
strangulated  hernia  with  a  mortality  of  only  ten  or 
twelve." 

"  One  case  I  think  is  a  little  remarkable.  Oper- 
ated on  a  man  aged  eighty-three,  right  inguinal 
hernia,  strangulated;  recovery  perfect,  but  one  year 
later  I  operated  on  the  same  man  for  left  strangulated 
hernia  and  he  made  a  good  recovery,  living  for  several 
years."  In  one  case  of  strangulated  femoral  hernia, 
in  an  elderly  woman,  the  right  ovary  was  found  in  the 
hernial  sac.  Recovery  excellent.  Dr.  Mackie  opens 
the  sac,  closes  the  wound  by  deep  cat-gut  sutures,  and 
dresses  antiseptically. 

Dr.  A.  Van  Der  Veer,*  of  Albany,  reports  two 
cases  of  strangulated  femoral  hernia,  operated  on 
under  antiseptic  precautions,  where  he  dissected  the 
sac,  and  ligated  at  the  neck  with  cat-gut  and  removed. 
Wound  closed  by  cat-gut  suture,  horse  hair  drain, 
careful  dressing  with  bichloride  gauze.  Second  dress- 
ing fourth  day  and  drainage  removed,  union   primary. 

Dr.  D.  G.  Wilcox,f  of  Buffalo,  reports  a  case  of 
irreducible  femoral  hernia,  operated  on  under  aseptic 
precautions.  Epigastric  artery  cut  and  tied.  Sac  dis- 
sected, pulled  down,  transfixed,  ligated  and  cut  off. 
Sutured  to  ring  with  catgut,  and  wound  closed.  Union 
primary  and  recovery  rapid.  At  three  months  seems 
cured,  wears  a  truss  as  a  precautionary  measure. 

♦Albany  Medical  Annals,  Oct.,  1888. 

f North  American  Journal  of  Homeopathy,  Oct.,  1888. 


CHAPTER  XL 

CONDITIONS     RENDERING     OPERATIVE     MEAS- 
URES ADVISABLE. 

As  a  resume  of  the  chapters  upon  operative  pro- 
cedures, hernia  may  be  considered  from  the  surgical 
standpoint  under  the  following  conditions: 

In  Children. — It  may  be  accepted,  that  in  a  con- 
siderable percentage  of  children,  hernia  results  from 
a  delayed  or  imperfect  development,  where  the  in- 
guinal canal  is  abnormally  open.  In  this  class,  if 
suitable  care  can  be  exercised  and  pressure  be  brought 
continuously  upon  the  canal,  especially  at  the  internal 
ring,  cures  may  often  be  rapid  and  permanent.  It 
should  be  the  aim  of  the  surgeon  to  effect  this  by  a 
carefully  adapted  support,  supplemented  by  proper 
nursing  and  care.  Although  enthusiastic  from  the 
conviction  of  safe  surgical  treatment,  it  is  wise  to  keep 
in  remembrance  the  value  derived  from  trusses.  The 
surgeon  should  consider  it  his  personal  duty,  not  to  be 
relegated  to  the  mechanician,  to  keep  his  truss-wear- 
ing patients,  especially  children,  under  his  own  obser- 
vation. 

Dr.  W.  B.  DeGarmo,*  of  New  York  gives  the  re- 
sults of  the  mechanical  treatment  of  hernia  in  the 
analysis  of  one  thousand  cases  in   private   practice; 


*New  York  Med,  Jour.,  March  3,  1888,  pp.  236.  237. 


—  215  — 
over  one-fourth  of  the  entire  number  was  dismissed  as 
cured,  /.  <?.,  all  remaining  so  for  at  least  six  months 
without  support;  one-third  improved,  i.  e.,  able  to 
wear  a  lighter  truss  than  at  first  and  remaining  com- 
fortable. 

He  concludes  that,  by  early  mechanical  treat- 
ment, a  large  percentage  of  hernise  occurring  under 
middle  age  can  be  cured. 

About  twelve  per  cent,  of  Dr.  DeGarmo's  cases 
were  under  five  years  of  age. 

Constipation,  tight  bandaging  of  the  abdomen, 
are  common  causes  of  hernia  in  infants.  Phymosis  is 
a  sufficiently  common  cause  to  be  borne  in  mind. 

On  the  other  hand,  in  the  earlier  years,  it  is  very 
difficult  to  fit  and  retain  a  truss  in  position.  This  is 
emphasized  by  the  experience  of  each  additional  case, 
and  not  seldom  is  instrument  after  instrument  thrown 
aside  in  despair.  Shall  we,  as  the  medical  advisor,  let 
hernia  in  childhood  remain  uncured  ?  If  the  farmer 
has  a  colt  thus  affected,  and  this  is  not  a  rare  condi- 
tion in  colts,  will  he  allow  the  animal  to  grow  up  dis 
abled  ?  The  veterinary  surgeon  does  not  hesitate  to 
operate  for  cure  and  with  very  few  failures. 

If  the  sufferer  is  an  orphan  boy,  dependant  in  the 
early  future  upon  his  developing  physical  powers,  as 
a  bread  winner,  is  it  the  duty  of  the  profession  to 
allow  the  poor  youth  to  enter  the  race  for  life,  often 
for  existence,  handicapped  at  the  start?  He  is  un- 
fitted for  hard  work,  cannot  enter  the   public  service 


2l6    

where  a  physical  examination  is  required,  and  is  de- 
barred from  many  avenues  where  success  and  position 
may  be  secured. 

In  Mr.  Spanton,  the  English  people  have  an  able 
advocate  for  early  operative  cure.  In  his  address  be- 
fore the  International  Medical  Congress*  he  writes: 
"  The  number  of  cures  effected  by  trusses  is  infinitesi- 
mal, if  we  may  judge  from  the  report  of  the  London 
Truss  Society,  where  we  find  that  of  a  total  of  96,886 
persons  relieved  by  trusses,  only  4,387  are  stated  to 
have  been  cured,  /.  e.  4.53  per  cent. 

Now,  if  it  be  possible  to  effect  the  cure  of  rupture 
early  in  life  (thereby  eliminating  at  once  one-eighth  of 
the  whole  number  of  cases)  by  an  operation  which 
shall  be  both  safe  and  efficient,  we  are  led  to  enquire, 
in  the  words  of  Mr.  Spencer  Wells,  ^'Whether  it  may 
not  be  better  to  operate  even  on  young  children, 
than  to  expose  them  for  several  years  to  the  incon- 
venience of  a  truss,  with  the  probability  that,  after  all, 
a  radical  cure  may  not  be  obtained? 

Parents  have  a  certain  duty  to  perform  towards 
their  offspring  in  the  matter  of  physical  defects;  and 
in  the  performance  of  this  duty,  it  is  generally  the 
province  of  the  medical  advisor  to  recommend  the 
course  which  should  be  pursued.  Hernia  is  surely  a 
source  of  greater  risk  to  life  than  club-foot,  or  hare- 


*0n  the  Cure  of  Hernia,  in  Relation  to  Parents  and  the 
Profession.  By  W.  D.  Spanton.  Trans.  International  Con- 
gress, 1881,  vol.  ii,  pp.  448-51. 


—    217    — 

lip,  or  naevus,  a  crooked  limb,  or  an  ankylosed  joint. 
Yet  these  are  conditions  for  which  an  operation,  and 
not  unfrequently  a  fatal  one,  is  readily  admitted  and 
recommended;  whereas  it  is  thought  usually  sufficient 
to  palliate  hernia,  by  the  advice  to  wear  a  truss,  and 
allow  the  dangers  and  other  drawbacks  incident  to  it 
to  continue  uncured.  It  is  time  this  opinion  changed, 
and  I  feel  convinced  that  those  who  will  not  be  un- 
willing to  see  for  themselves  the  advantages  of  an 
operation  for  the  cure  of  hernia,  over  the  uncertain 
and  unsatisfactory  treatment  with  trusses,  will,  in  a  large 
number  of  cases,  advocate  its  adoption.  Operative 
measures,  in  modern  days,  have  not  had  a  fair  trial; 
they  have  not  been  carried  out  on  a  sufficiently  ex- 
tensive scale  to  demonstrate  their  real  value." 

The  knowledge  and  adoption  of  antiseptic  opera- 
tive measures  whi-ch  have  become  general  since  the 
date  of  Mr.  Spanton's  writing,  gives  yet  more  force  to 
his  earnest  plea  in  behalf  of  this  large  class  of  helpless 
sufferers. 

When  it  shall  have  been  determined  wise  to  oper- 
ate in  childhood,  there  is  little  to  emphasize  about 
the  operation  which  does  not  pertain  to  adult  life. 
All  the  tissues  are  more  delicate,  they  are  vascular, 
but,  on  this  account,  will  admit  of  the  more  rapid  re- 
pair. The  sac  is  usually  very  thin,  and  it  may  be 
more  troublesome  to  manipulate  than  in  adults.  On 
the  other  hand,  its  surgical  treatment  is  of  less  im- 
portance.    If  easy  to  be  separated,  let  it  be  treated  by 


—    2l8    — 

dissection,  ligation,  or  suture  at  neck,  and  removed  as 
in  adults.  If  congenital  rather  than  acquired,  it  is 
best  to  suture  across,  in  order  .to  complete  the  tunica 
vaginalis  testis,  and  close  it  down  upon  the  cord,  then 
continue  the  buried  animal  suturing  so  as  to  close 
and,  as  far  as  possible,  increase  the  obliquity  of  the 
canal.  Care  must  be  exercised  not  to  press  too  closely 
upon  the  cord,  but  when  the  cord  is  only  pressed 
upon,  in  an  even  continuous  seam,  it  is  surprising  to 
note,  if  the  wound  is  aseptic,  how  little  the  scrotum 
and  its  contents  suffer  in  their  nutrition.  Sepsis  and 
its  result  is  the  usual  cause  of  scrotal  edema,  etc., 
which  has  generally  been  ascribed  to  pressure  upon 
the  vessels  of  the  cord.  If,  after  the  operation,  the 
aseptic  state  is  maintained,  edema  in  any  degree,  or 
even  tenderness  of  the  scrotum,  is  the  decided  excep- 
tion. When  the  canal  is  reformed,  and  the  rings 
properly  closed,  continue  the  suturing  of  the  tissues, 
in  evenly  approximated  layers,  until  the  lips  of  the 
wound  are  in  close  juxtaposition  including  the  skin, 
and  all  by  the  use  of  a  fine  buried  tendon  suture.  In 
this  way  the  tissues  are  held  at  complete  rest,  without 
hemorrhage  or  separation,  and  nothing  is  left  to  drain, 
therefore  the  drainage  tube  or  its  equivalent  is  avoided. 
This  is  of  the  first  importance,  especially  in  children, 
since  it  allows  the  complete  closure  of  a  wound,  which 
the  competent  surgeon  can  make  aseptic,  and  its  her- 
metic sealing  from  subsequent  infection.  This  is  as- 
sured in  a  dried  wound,  dusted  with   iodoform  and 


—  219  — 
covered  with  iodoform  collodion,  into  which  a  few 
fibres  of  cotton  have  been  incorporated.  To  the  sur- 
geon, who  has  labored  for  years  to  secure  an  aseptic 
dressing  with  pads,  gauze,  bandages,  macintosh,  anti- 
septic cotton,  or  wool,  until  he  made  a  little  mummy 
of  his  patient,  only  to  find,  after  all  his  care,  that  the 
doubly  restless  little  prisoner  had  generally  succeeded 
in  both  urinary  and  fecal  defilement  of  all  his  protec- 
tion, such  germ  proof  dressing  will  be  welcomed  as 
the  near  approach  to  perfection. 

Dr.  Gerster,*  of  New  York,  advocates  the  opera- 
tion, in  children,  by  closing  the  neck  of  the  sac  and 
packing  the  wound  with  iodoform  gauze,  treating  it  as 
an  open  wound  to  heal  by  granulation.  This  he  pre- 
fers, since,  in  children,  there  is  so  much  difficulty  in 
keeping  the  wound  from  being  soiled  by  the  excre- 
tions, and  deep-seated  septic  inflammations  result. 

The  quiet  of  the  bed,  with  light  diet,  loose  dejec- 
tions, the  interest  and  amusements  of  playthings,  and 
the  little  patient  will  hardly  seem  sick,  and  I  think  the 
statistics  of  to-day  are  sufficient  to  warrant,  in  com- 
petent hands,  a  mortality  not  to  exceed  one  per  cent., 
with  not  less  than  seventy-five  per  cent,  of  permanent 
cures.  I  hazard  little  in  predicting  that  greater 
familiarity  with  the  operation,  with  careful  attention 
to  detail,  will  make  the  result  as  certain  as  in  almost 
any  operation  in  surgery. 


*0n  Strangulated  Hernia  in  Children,  by  A.  G.  Gerster, 
N.  Y.  Med.  Jour.,  Jan.  2r,  1888,  p.  71. 


ij£  mmm  mmmm  col* 


The  age  at  which  operation  may  be  advised  will 
depend  upon  condition.  There  is  nothing  in  age,  per 
sg,  to  debar  operation. 

I  operated  upon  one  little  fellow  only  sixteen 
months  old,  and  he  continued  nursing  during  the 
few  days  he  was  under  care,  and  scarcely  once  cried, 
as  if  in  pain.  When  dismissed  from  observation,  three 
months  after,  the  cure  appeared  complete. 

OPERATIVE    PROCEDURES  IN   ADULTS. 

Inguinal  Hernia  in  Woman. — The  radical  cure 
should  be  seriously  considered  in  all  cases,  occurring 
in  the  female,  where  difficulty  of  retention  or  serious 
inconvenience  results.  Age,  occupation,  social  posi- 
tion, etc.,  are,  as  ever  in  surgery,  factors  in  the 
problem. 

Operation,  in  woman,  is  to  be  the  more  favorably 
considered,  since  the  absence  of  the  cord  allows  a 
complete  and  firm  closure  of  the  canal. 

Inguinal  Hernia  in  the  Male. — As  I  pointed  out, 
when  discussing  the  etiology  of  hernia,  the  large  pro- 
portion of  the  cases  are  of  this  variety,  and  operative 
measures,  to  effect  a  radical  cure  of  hernia,  must  be 
especially  adapted  to  be  applicable  to  this  class.  I  have 
traced,  in  detail,  with  special  care,  the  history  of  oper- 
ations, attempted  for  this  end,  through  the  literature 
of  surgery,  since  the  problem  for,  at  least  a  century 
has  been  clearly  defined  in  its  varying  factorage,  and 
the   best   minds   of  the   generations  have   given  un- 


221     

wearied,  devoted  study  to  the  subject.  The  necessary 
patency  of  the  canal  is  the  condition,  more  than  any 
other,  which  has  been  the  reason  of  failure.  To  con- 
strict and  not  occlude,  to  allow  a  free  escape  of  the 
cord  with  unimpaired  circulation  and  function,  and 
retain  all  beside,  is  a  problem,  the  happy  solution  of 
which,  by  a  delicate  adjustment  of  means  to  ends,  is 
scarcely  exceeded  in  all  surgery. 

For  a  considerable  period,  the  resultant  cure  was 
effected  by  the  sacrifice  of  a  testicle  and  cord,  and  the 
end  attained  by  this  measure  was  so  satisfactory  that 
such  numbers  sought  relief  at  this  cost,  it  was  forbid- 
den by  legislative  enactment.  Open  dissections  fell 
into  disuse,  only  to  be  revived  within  the  last  few 
years.  Subcutaneous  closure  with  the  wire  suture,  in 
a  manner,  led  up  to,  and  made  the  way  for  again  re- 
sorting to  the  open  wound  method,  and  closure  of  the 
canal  and  rings  by  buried  sutures.  Success  by  this 
method,  however,  could  not  be  assured  until  antiseptic 
surgery  taught  the  measures  necessary  to  secure  the 
closing  and  retention  of  the  wound  free  from  infec- 
tion. In  the  review  of  the  recent  literature,  which  I 
have  given  at  length  in  a  former  chapter,  it  is  shown 
by  abundant  demonstration,  that  the  operation  for  the 
permanent  cure  of  hernia  may  be  entered  upon  with 
the  assurance  of  success,  almost,  if  not  quite  equal  to 
that  of  any  well  established  surgical  procedure. 

I  have  quoted  reports  of  operators  who  have 
given    779   cases   with   only   five    deaths,    and    these 


are  explained  as  having  been  produced  by  causes 
other  than  from  the  operation.  The  remote  results 
are  not  sufficiently  defined  to  tabulate,  for  the  reason 
that  most  operators  agree  that  it  is  necessary  that  a 
case  should  remain  for  a  considerable  length  of  time 
without  evidence  of  return,  before  being  classified  as 
permanently,  or  radically  cured. 

The  general  consensus  of  surgical  opinion,  at 
present,  emphasizes  the  factorage  of  operative  meas- 
ures in  the  treatment  of  inguinal  hernia  as: 

1.  The  free  dissection,  or  open  wound  method, 
under  rigid  antiseptic  precautions. 

2.  The  treatment  of  the  sac. 

All  agree  to  the  importance  of  the  peritoneal 
pouch  as  a  factor.  At  present  it  is  treated  in  a  variety 
of  ways. 

It  may  be  returned  unopened,  and  the  canal 
closed. 

When  this  is  done,  especially  when  the  hernia 
is  small  and  the  internal  ring  remains  firm,  it  is  fair  to 
assume  that  it  slowly  contracts  and  becomes  greatly 
diminished  in  size,  very  probable  is  often  consolidated 
into  a  puckered  mass,  which  remains,  for  a  consider- 
able period,  as  an  indurated  swelling.  This  may 
serve  as  a  wedge  to  reopen  the  pillars  of  the  ring, 
rather  than  as  a  buttress  of  defense.  When  a  de- 
pression over  the  internal  ring  remains,  we  not  only 
have  a  peritoneal  pouch,  but  a  weakened,  slightly 
open  ring.     In  this  condition,  the  wave-like  motions 


—     223    — 

of  the  fluid  intestinal  contents  will  impinge  into  the 
recess,  very  likely  to  re-form  a  hernia,  which,  upon 
severe  strain,  comes  to  the  knowledge  of  the  sufferer 
as  a  rupture  occurring  suddenly. 

If  the  sac  is  of  considerable  size,  the  general 
opinion,  although  not  accepted  by  all,  is  that  it  should 
first  be  opened,  to  ascertain  its  contents,  if  any,  and 
its  relation  to  the  canal  and  rings.  The  objection 
urged  against  its  opening  is  that  it  is  continuous  into 
the  abdominal  cavity,  and  a  peritonitis  might  be  en- 
gendered. This  is  not,  however,  considered  valid  by 
antiseptic  operators. 

It  is  also  generally  advised  to  dissect  the  sac  after 
opening,  quite  freely,  to  within  the  internal  ring;  and 
this  for  the  purpose  of  securely  closing  its  abdominal 
orifice.  The  profession  are  divided  as  to  the  best  means 
of  effecting  this  closure.  The  larger  majority  advocate 
the  ligature  or  suture,  some  adopt  Mr.  Ball's  method 
of  twisting  the  sac  and  a  retaining  suture,  as  more 
likely  to  obliterate  the  peritoneal  pouch;  others,  more 
recently,  have  followed  Mr.  Macewen,  in  the  adop- 
tion of  his  ingenious  method  of  puckering  into  folds 
the  sac,  and  drawing  it  quite  within  the  ring  to  be- 
come attached  and  serve  as  a  buttress  to  deflect  the 
intestinal  impulse. 

In  the  careful  review  upon  the  formation  of  the 
sac,  it  was  shown  that  the  normal  peritoneum,  within 
a  considerable  limit,  is  elastic  and  there  can  be  little 
doubt  but  that,  when  the  sac  is  freed  quite  within  the 


224    

ring,  it  can  be  safely  drawn  down  and  ligatured  or 
sutured,  so  that  no  depression  results.  I  have  verified 
this  in  one  case  at  post-mortem  examination,  where  I 
sutured  the  neck.  In  one  case  also,  three  months 
after  operation,  I  found  a  slight  peritoneal  depression, 
where  I  returned  the  sac  unopened.  When  well 
drawn  down  and  the  ligature  tightly  applied,  the 
puckering  in  folds  occurs  quite  as  in  Mr.  Ball's 
method  of  twisting. 

The  advantages  of  Mr.  Macewen's  buttress  are 
probably  theoretic,  rather  than  real.  The  use  of  the 
sac,  as  a  plug  to  close  the  ring,  sutured  and  retained, 
has  very  generally  been  abandoned  as  unsatisfactory. 
Nearly  all  operators,  at  present,  think  the  sac  an  ab- 
normal, deleterious  portion  of  useless  material  to  be 
removed.  Utilized  as  proposed  by  Mr.  Macwen, 
if  it  forms  a  buttress,  as  supposed,  to  receive  the  in- 
testinal impulse,  may  it  not  be  equally  inferred  that  it 
would  be  likely  to  act  as  a  wedge  to  press  unevenly 
against  the  newly  formed  tissues  of  the  restored  canal 
and  thereby  cause  harm,  rather  than  serve  as  a  de- 
flector of  pressure  ?  Although  the  peritoneum  forms  a 
pouch  or  pocket  surrounding  the  hernial  contents, 
nature  did  not  intend  it  to  serve  as  a  part  of  the  sup- 
porting abdominal  wall,  but  by  an  even,  elastic,  smooth 
surface,  lining  the  firm  muscular  and  tendinous  struc- 
tures, to  allow  the  abdominal  contents  to  glide  easily 
and  evenly  in  every  direction.  It  is  very  probable 
that,  when  the  peritoneum  is  thus  disposed  of,  its  vas- 


—    225     — 

cularity  and  nutrition  reduced  to  the  minimum,  ab- 
sorption slowly  ensues  and,  in  the  end,  leaves  a  smooth 
even  surface.  If  Mr.  Macewen's  disposition  of  the 
sac  is  an  improvement  by  serving,  as  he  thinks,  as  a 
reinforcement  of  the  parts,  it  might,  by  some,  be  in- 
ferred that  this  construction  should  have  entered  into 
the  primal  organization  of  mankind. 

It  has  seemed  to  me,  that  the  wise  effort  of  the 
surgeon  should  be  to  restore,  as  far  as  possible,  the 
primal  conditions.  The  peritoneum  is  normally 
slightly  introflected  at  the  ring,  but  loosely  attached, 
and  may  be  moved  quite  freely  by  slight  traction  in 
all  directions,  independent  of  other  structures  of  the 
abdominal  wall.  When  it  is  considered  that  the  in- 
ternal ring  is  ovate,  rather  than  circular,  it  would  seem 
best,  in  closing  the  sac,  at  its  mouth,  to  do  this  in  the 
direction  of  its  longer  diameter,  as  less  likely  to  leave 
folds.  This  gives  as  the  resultant,  a  smooth,  rather 
than  puckered  peritoneum,  in  the  largest  degree  vital- 
ized and  resiliant,  as  freely  movable  as  possible  upon 
its  exterior  loosely  attached  fascia.  In  the  attempt  at 
this,  no  method  would  appear  superior  to  the  evenly 
closed  mouth  of  the  sac  by  a  continuous  seam. 

However,  there  can  be  no  doubt  that  good  results 
follow  any  method  which  closes  the  mouth  of  the  sac 
and  causes  its  obliteration. 

l6   DD 


CHAPTER  XII. 

METHOD  OF  OPERATION. 

More  important,  in  my  judgment,  than  the  dis- 
position of  the  sac,  is  the  subsequent  treatment  of  the 
wound.     Here  again  authors  are  at  variance. 

A  small  class  think  the  removal  of  the  sac  all  suf- 
ficient to  effect  a  cure.  However,  it  needs  little  argu- 
ment to  show,  if  cure  results,  it  is  not  from  the  closure 
of  the  peritoneum  alone,  but  the  rather,  to  the  firm 
union  ensuing  in  the  wound.  The  patient,  in  the 
horizontal  position,  without  strain  to  the  abdominal 
wall,  the  wound,  even  if  open  and  septic,  naturally 
cicatrizes  slowly,  but  firmly,  and  there  can  be  no 
doubt  many  excellent  results  follow.  Several  opera- 
tors have  deliberately  chosen  this  method,  the  wound 
aseptic,  by  packing  with  iodoform  dressing,  as  both 
safe  and  advantageous.  It  is  not  very  unlike  an 
aseptic  wound  kept  open  to  its  base  by  a  large  drain- 
age tube.  To  this  method,  however,  there  are  several 
objections.  First,  it  does  not  allow  of  a  reformation 
of  the  obliquity  of  the  canal.  Second,  a  granulating 
wound,  even  aseptic,  heals  slowly  and  the  resultant 
cicatrix,  if  firm,  is  inelastic  and  often  painful  for  a 
long  time. 

In  a  former  chapter,  in  the  study  of  the  anatomy 
of  the  inguinal  canal,  it  was  pointed  out  that  nature 
designedly  constructed  it  to  course  through  the  abdo- 


■■>i\'Si^^(,46i'; 


ifelwff 


Fig.  15. 


Inguinal  Hernia,   showing   tlie   first   stitch  taken  for  the  closure  of  the   internal   ring  from 
below  upwards  in  order  to  reform  the  inguinal  canal.     See  also  pages  84  and  85. 


—    228    — 

minal  wall,  so  obliquely  that  ordinary  pressure  from 
within  outwards  served  to  bring  its  walls  into  lateral 
apposition. 

The  most  important  of  all  the  measures  to  be 
sought  in  the  cure  of  hernia,  in  my  judgment,  is  the 
restoration  of  the  obliquity  of  the  canal.  This  can 
only  be  effected  by  the  open  dissection  method,  since 
the  restoration  must  commence  at  the  internal  ring. 
I  cannot  help  thinking  that  to  this,  rather  than  the 
peculiar  disposition  of  the  sac,  is  owing  the  excellent 
results  of  Mr.  Macewen's  operation.  His  method  of 
restoration  of  the  canal  is  excellent.  Where  the 
hernia  is  old  and  large,  the  parts  are  deformed  and 
the  criticism  of  Mr.  Banks  is  justly  taken,  that  the 
aponeurosis  of  the  external  oblique,  stretched  and  at- 
tenuated, leaves  little  material  for  the  suturing  of  the 
external  ring.  In  these  instances,  the  hernia  ap- 
proaches to  the  form,  called  direct,  /.  e.,  the  opening 
appears  to  be  almost  at  right  angles  to  the  abdominal 
wall.  It  is,  in  this  class  of  cases,  that  the  cure  of 
hernia  is  especially  difficult.  The  method  advocated 
and  practiced  with  such  success  by  Prof.  Bassini  and 
myself,  seems  the  one  to  be  adopted.  The  cord  is 
pushed  gently  aside,  and  the  internal  ring  is  narrowed 
from  below  and  within,  upwards  and  outwards,  leav- 
ing only  sufficient  space  for  the  cord  at  its  upper  and 
outer  border.  This  is  best  effected  by  the  double, 
tendon  suture,  and  is  not  nearly  as  difficult  as  would 
appear.     The  base  or  under  portion  of  the  canal  thus 


Fig.  i6. 
Inguinal  Hernia,  showing  the  manner  of  closure  of  ihe  internal  ring  with  the  double  continu- 
ous tendon  suture.     The  needle  rethreaded  for  withdrawal. 


—  230  — 

reformed,  the  cord  is  replaced,  and  the  outer  and 
superficial  layers  are  closed  from  above  downwards  by 
the  same  double  suture,  in  even  continuous  seam,  as 
far  inwards  upon  the  pillars  of  the  ring  as  safety  to 
the  cord  will  permit. 

The  cord  may  thus  be  inclosed  within  a  canal, 
restored  to  its  normal  size,  length,  and  obliquity.  The 
superficial  tissues,  as  also  the  skin,  are  closely  and 
evenly  approximated  by  the  buried  animal  suture  as 
described  in  the  treatment  of  the  wound  in  strangulated 
hernia.  This  is  the  more  important  since  we  are  en- 
abled to  do  away  with  the  drainage  tube;  never  needed 
in  any  wound,  when  healthy  aseptic  surfaces  can  be 
approximated,  but  invaluable  in  septic  wounds. 

The  avoidance  of  the  drainage  tube  renders 
available  the  closure  of  the  wound  by  a  germ-proof 
dressing  of  iodoform  collodion,  the  advantages  of 
which  have  previously  been  emphasized. 

If  the  above  methods  of  operation  for  the  radical 
cure  of  inguinal  hernia,  as  now  appear,  are  the  best 
which  surgery  can  at  present  furnish,  and  if  they  are 
as  safe  in  competent  hands  as  the  collated  experience 
seems  to  show,  in  what  cases  or  class  of  cases  should 
the  operation  be  advised  ? 

I.  All  agree,  every  case  operated  on  for  strangu- 
lation, should  be  given  the  advantages  to  be  derived 
from  the  attempt  at  cure.  This  we  have  seen,  so  far 
as  the  wound  itself  is  concerned,  independent  of  the 
condition  of  the  hernial   contents,  affords  conditions 


"B0//lf^ 


Fig.  i-j. 
Femoral  Hernia.     The  first  stitch  taken  parallel  to  vein  for  closing  the  crural  ring.     See  also 
page  TOO. 


—    232    — 

not  much  less  favorable  for  cure,  than  when  under- 
taken primarily  for  this  object. 

2.  It  should  be  advised  in  the  large  majority  of 
cases  of  irreducible  herniae,  and  where  much  difficulty 
is  experienced  in  retaining  the  parts  in  situ  by  a  truss. 

3.  There  are  often  other  reasons  which  would 
influence  a  favorable  consideration  for  operation;  such 
as  occupation,  change  of  residence  to  surroundings 
where  surgical  aid  could  not  be  furnished  in  case  of 
need,  as  for  example,  a  residence  in  the  Colonies, 
India,  South  America,  the  Northwest. 

FEMORAL    HERNIA. 

What  has  been  said  in  relation  to  the  operation 
for  the  cure  of  inguinal  hernia,  may  be  emphasized 
when  we  consider  the  operative  measures  for  femoral 
hernia.  The  relation  of  the  sac  and  its  contents  to 
the  surrounding  parts,  already  fully  discussed  in  a 
previous  chapter,  teaches  the  greatly  increased  danger 
of  this  variety. 

When  the  sac  is  sufficiently  large  to  allow  the  oc- 
casional invagination  of  a  loop  of  intestine,  the  indi- 
vidual runs  a  risk  of  life  not  to  be  underestimated. 
The  retention  by  a  truss  is  more  difficult,  and  when 
strangulation  occurs,  the  danger  is  much  greater  than 
in  strangulation  of  the  inguinal  variety,  owing  to 
the  tense,  firm,  sharp  border  of  the  ring. 

Until  recently,  the  radical  cure  of  femoral  hernia 
was  scarcely  considered,  except  following  operations 


Femoral  Hernia,  showing  a  third  stitch  taken  for  the  closing  of 
the  canal  by  the  use  of  the  double  continuous  tendon  suture. 
The  stitches  are  represented  as  loosly  drawn  in  order  to  the 
better  show  the  method  of  suturing.  The  needle  is  passed 
through  the  firm  pubic  fascia  and  the  outer  border  of  the 
saphenous  opening  and  when  drawn  closely  will  fold  the  lat;er 
inwards. 


—  234  — 
for  strangulation.  Mr.  Macewen's  method  for  the 
closure  of  the  ring  and  narrowing  of  the  canal,  as 
illustrated  in  the  case  of  Dr.  H.  W.  Gushing,  of  Bos- 
ton, is  excellent.  The  disposition  of  the  sac,  however, 
after  his  method,  is  open  to  more  serious  objection 
than  in  inguinal  hernia,  making,  almost  of  necessity,  a 
hard,  painful  swelling,  slow  to  disappear.  The  opera- 
tion, as  described  in  a  former  chapter  for  strangulated 
femoral  hernia,  need  not  be  repeated  here.  To  one 
familiar  with  the  anatomy,  the  dissection  is  not  diffi- 
cult and  the  introduction  of  the  sutures  quite  easy. 
The  incision  often  may  not  be  a  long  one.  The 
success  is  dependent  upon  doing  away  with  the  sac, 
and  the  narrowing  of  the  ring  and  canal  to  the  mini- 
mum, consistent  with  safety  to  the  vessels.  When  this 
is  done  antiseptically,  it  is  surprising  to  note  how 
closely  the  vessels  may  be  closed  down  upon,  without 
the  slightest  disturbance  of  the  circulation. 

UMBILICAL    HERNIA. 

Little  is  required  to  be  added  to  the  discussion 
already  entered  into  in  a  former  chapter  upon  strang- 
ulated umbilical  hernia. 

Laparotomy,  in  the  hands  of  many  surgeons,  is 
now  considered  of  itself  of  so  slight  danger,  as  to  be 
counted  a  minor  operation.  This  is  certainly  true  in 
exploratory  incisions,  under  careful  antiseptic  condi- 
tions. 

The  removal  of  an  umbilical  hernial  sac  is  scarcely 


—  235  — 
more  than  an  exploratory  operation.     In  the  reducible 
variety,  the   abdominal  contents    are    not    disturbed, 
scarcely  seen.     The  sac  is  resected  and  the  parietal 
walls  closed.     When  we  remember  that  the  intra-ab- 


Fig.  19. 

Femoral  Hernia,  showeng  the  crural  ring  closed 
by  means  of  the  double  continuous  animal 
suture.  Stitches  loose  to  show  method  of 
suturing. 


dominal  tension  is  generally  much  greater  than  nor- 
mal, it  is  usually  wise  to  pass  so-called  retaining 
sutures,  to  entirely  include  the  suturing  of  the  wound, 
thereby  holding  it,  as  in  a  splint,  at  rest  until  union  is 


—  236  — 

effected.  It  is  generally  advisable  to  do  this  with  wire 
passed  quite  outside  the  other  sutures,  and  external  to 
the  peritoneum.  These  are  placed  in  position  after 
the  peritoneum  has  first  been  closed  by  a  continuous 
animal  suture,  and  are  not  twisted  until  after  the  ex- 
ternal wound  has  been  hermetically  sealed.  Drainage 
is  unnecessary  when  the  wound  has  been  aseptically 
closed  in  layers  of  buried  sutures,  as  in  all  the  other 
varieties.  It  is,  however,  for  obvious  reasons,  less 
dangerous  in  its  use  than  about  the  groin. 

Ventral  hernia  of  any  variety  may  be  classed  with 
the  umbilical  in  the  general  direction  for  operative 
measures. 

In  conclusion,  the  details  of  the  open  wound 
operative  method,  advocated  in  the  treatment  of  the 
varieties  of  hernia  consist: 

I,  Preparation.  —  Disinfect  carefully  operator, 
assistants,   sponges,  and  instruments. 

Maintain  strict  asepsis  during  the  operation  with 
the  same  care  as  in  laparotomy. 

Place  the  patient  upon  a  table  in  a  good  light. 

Carefully  shave  the  parts. 

Disinfect  by  scrubbing  with  brush  and  soap  in 
i-iooo  mercuric  bichloride  solution. 

Cover  with  light  rubber  cloth  the  abdomen  and 
thighs  except  about  the  hernial  region. 

Place  over  these  towels  wrung  from  the  i-iooo 
mercuric  solution. 

Conduct  the'stages  of  the  operation  under  irriga- 


—  237  — 
tion  with  the  mercuric  solution  1-2000  until  the  last 
stitch  is  taken. 

Often  not  a  single  sponge  is  required  and  each 
step  of  the  operation  can  be  directed  by  seeing  exactly 
the  state  of  the  parts. 

2.  The  Sac. — The  sac  should  generally  be 
opened  and  dissected  free,  quite  within  the  ring; 
sutured  across  at  its  very  base,  and  removed. 

3.  The  Reconstruction  by  Buried  Animal  Sutures. 
— The  reformed  peritoneum  is  allowed  to  retract  with- 
in the  abdominal  wall. 

The  pillars  of  the  ring  are  slightly  refreshed. 

The  posterior  wall  of  the  canal  is  reformed  by 
narrowing  the  internal  ring  from  below  upwards  and 
outwards.  This  is  best,  and  perhaps  easiest  done  by 
buried  tendon  sutures,  applied  in  an  even,  continuous 
double  stitch. 

The  pillars  of  the  ring  are  closed  downwards,  in 
the  same  manner,  as  far  as  safety  to  the  cord  will  per- 
mit. 

4.  The  Treatment  of  the  Wound. — The  super- 
ficial tissues  are  brought  into  juxtaposition  by  a  line  of 
continuous  buried  animal  sutures,  and  the  skin  coapted 
by  a  running  blind  stitch  taken  from  side  to  side 
through  the  deep  layer  of  the  skin.  In  this  way  the 
divided  tissues  are  rejoined  and  drainage  is  not  re- 
quired. The  line  of  the  incision  is  dried,  dusted  with 
iodoform,  and  sealed  with  iodoform  collodion.  A  soft 
wool  pad  is  usually  applied  for  protection,  but  is  re- 
quired for  no  other  purpose. 


—  238  — 

The  advisability  of  when  to  operate,  in  any  given 
variety  of  hernia,  is  always  to  be  seriously  considered 
as  an  independent  problem,  the  factorage  of  which 
must  consist  of  many  individual  details. 

There  can  be  little  doubt  the  surgery  of  the 
future  will  include  a  large  percentage  of  the  sufferers 
from  hernia  which  the  conservative  surgeon  of  to-day 
relegates  to  the  truss-bearing  army  of  invalids.  My 
own  feeling,  in  the  conclusion  of  my  labors,  cannot  be 
better  expressed  than  in  the  noble  words  of  Sir  Spencer 
Wells,  who  wrote  in  1858:  "The  relief  of  a  strangu- 
lated hernia  is  justly  regarded  as  one  of  the  noblest 
triumphs  of  operative  surgery.  The  surgeon  saves 
the  life  of  the  patient  without  removing  or  deforming 
any  part  of  his  body.  But  the  surgeon  who  cures 
hernia  radically,  with  certainty  and  safety,  is  a  greater 
public  benefactor,  as  he  not  only  relieves  large  num- 
bers of  his  fellow-creatures  from  suffering,  but  he 
averts  the  danger  of  a  strangulation  to  which  they  are 
continually  exposed,  in  a  greater  or  less,  degree, 
through  every  period  of  life." 


INDEX. 


A.  PAGES. 

Abdominal  Hernia i,  97,   115,  125 

Supports 54.   138,  214 

Abernethy,  John 134 

Accidental  Hernia 60,  117 

Acrel 134 

Acquired  Congenital  Hernia 24,  185 

Adhesions  of  Sac 27 

Adjustment  of  Trusses 56,  123 

Aeginata  Paulus 128 

Age  as  Affecting  Hernia 8,  9,   175,  214 

Agnew,  D.  H 158 

Albucasis 128 

Alexander,    W , 193 

Allen,  Dudley  P 210 

Allis's  Herniotome 82 

Anatomy  of  Hernia 32 

Femoral  Hernia 89 

Inguinal  Hernia 33,  37,   50 

Strangulated  Hernia 64 

Umbilical  Hernia 113 

Andaregg 204 

Animal  Ligatures  in  Surgery 168,   170,  175 

Annandale,  Prof.  T 176 

Antiseptic  Measures  in  Cure  of  Hernia 83,   165,  222,  236 

Arnaud,  M 115 

Arteries,  Danger  of  Wounding 81 

Epigastric 45,   81,  94 

Obturator 94,  113 

Umbilical 120 


—  240  — 

PAGES. 

Author's  Operation  for  Radical  Cure  of  Hernia. . .   79,  85,   105 

124,   167,  226,  228 

of  Femoral 103,  232 

of  Inguinal. .  72,  227,  229 

of  Obturator 117 

of  Strangulated. .  .85,  230 
of  Umbilical. . .  .  124,  234 

Avicenna 128 

B. 

Ball  C.  B.,  Torsion  of  Sac 193 

Banks,  W.,  Mitchell 182 

Barker,  Arthur 186 

Bassini,  Prof 202 

Baxter,  J.  H.,  Tables 5.  6,  7,       9 

Belmas,  M 138 

Birket,  John 60,  83,   113 

Boinet,  A I45 

Bonnet,  M.  A 138 

Bradford,  E.  H 207 

Bubonocele 26,  69,  207 

Buchanan.  Prof.  George 193 

Burchard,  T.  H 207 

Burrell.  H.  L 211 

C. 

Camper,  Peter 32,     35 

Canal,  Formation  of 20,  46,     48 

Femoral 89,     97 

Inguinal 20,  41,     47 

of  Nuck 21 

Reformation  of 76,  108,  228,  237 

Carbolized  Catgut  Sutures 168,  176,  185.  211 

Carnochan,   Prof 142 


—     241    — 

PAGES. 

Castration  as  a  Means  of  Cure  of  Hernia 131 

Causes  of  Hernia 12,23,  97,  113 

Cauterization  as  a  Means  of  Cure - 128 

Championniere,   Lucas j32 

Chase,  Heber, -g 

Cheever,  D.  W 160 

Church,  M.  D ^ 

Clarke,  A.  P '.'.\y^^'..'.'.'.'^'.'.'.  166 

Ci  issification  of  Hernia i    2  8 

C'°q"^^'  J 17,28,34.9-4!   116 

Congenital  Hernia    23,49.88,   218 

Hydrocele 22 

Conjoined  Tendon ", ^g    j^o 

Cooper,  Astley,  Sir 14,  24,  32,  57,  60,  77,  97'  115 

^ 117 

Cord,  Spermatic 21,43,  218 

Cousen's  Ward '       '  j  _ 

Cremaster  Muscle 21      43 

Cribriform  Fascia gq'     Qg 

Croft,  J.   M _ *.**...  ....  ....    .'       8 

Cuenod,  Victor j_g 

Curling,  T.B .........'.'.'.'.'.[[ 20 

Cushing,  H.  W ^  211 

Czerney,  V.,  Prof .*.....    177 

D. 

Dangers  of  Wounding  Vessels gj 

Darling  W.      Boundaries  of  Canal *,_'      ,g 

Davenport,  J.  H . 

^     ^                            146 

De  Garmo,  W.  B 

'                    • 214 

Development  of  Hernia 12,  14,  23,  24,  49.  65,  97,  113,  120 

Diagnosis,  Importance  of  Early 72,  103,  iiiri24,  216,  223 

Diaphragmatic  Hernia 2'  127 

Direct  Inguinal  Hernia aa'  00^ 

17    DD  •^^'     ■^■^7 


242    

PAGES. 

Dowell,  G 158 

Duveney 116 

E. 

Elongation  of  Mesentery  as  Cause  of  Hernia 12 

Encysted  Hernia 24 

Enterocele * 2 

Entero  Epiplocele 52 

Epigastric  Artery 45,  81,  94 

Erdmann 205 

Eve  Paul 170 

Excision  of  Sac 85,107,125,173,    218,  237 

F. 

Fabricius  ab   Aqua  Pendente 128 

Falciform  Process 91,  107 

Fascia  Camper's 35 

Cribriform 89 

Deep  or  Fascia  lata 89,  92 

Propria 97 

Transversalis 39,  48 

Femoral  Canal . .  93 

Hernia 89,  92,  95,  100,  232 

Ring 93 

Ligament  of  Hey 91 

Formula  for  Injection — Heaton 140 

— Warren 147 

Franks  Kendall 1 84 

Frequency  of  Hernia  According  to  Age 8 

Locality 5 

Nationality 7 

Sex 4 

Funicular  Process 23 


—  243    — 

PAGES. 

G. 

Garengeot  Jacques io8 

Gay,  G.  W i6o 

Gerdy,  P.  M 137 

Gimbernat .    . .      93 

Gimbernat's  Ligament 36,  gi.  93,  105 

Greene,  N 58 

Gross,  S.  D 206 

Gubernaculum  Testis 20 

Guy's  Hospital  Reports 24,  51 

H. 

Haller,  A 23 

Holthouse  Carsten 140 

Hamilton,  John  B 206 

Hardie,  James   191 

Heaton,  G.  H 145 

Heath,  Christopher.  ...    187 

Hernia  Defined i 

Classified 2,  9 

Causation  of 9,  12,  23,  97,  113 

Frequency  of 4,  5,  7,  9 

In  Children 22,   121,  214 

In  Adults 113    175,  220 

Accidental 60,  117 

Acquired  Congenital 24,  185 

Congenital 23,  49,  88,  218 

Diaphragmatic 2,  127 

Encysted 24 

Femoral i,  89,  92,  94,  96,  232 

Incarcerated 14,  180,  181 

Inguinal i,  20,  33,  48,  51,  220,  227 

Irreducible 14,  59 

Ischiatic 2,  119 


—   244   — 

PAGES. 

Hernia,Oblique  Inguinal 4i>  48 

Perineal 2 

Reducible   Inguinal ....14,  52 

Scrotal 51.  60 

Strangulated 64,  67,  72,  79,  85,  234 

Umbilical ....120.  234 

Ventral 2,  127,  236 

Herniotomy 79 

Hesselbach.  F.  K 98 

Heuston.   F.  T 196 

Hey's  Ligament 91 

Hilton.  J 116 

History  of  Operations 128,  177.  206 

Hunter,  John 23 

Hydrocele  .  .• ■  .  19 

I. 

Incarcerated  Hernia 14,  iSo,  iSi 

Infantile  Hernia 22,  121 

Inguinal  Canal 20,41,  47 

Hernia i,  20,  33,  48.  51,  220,  227 

Injection  as  a  Cure  of  Hernia 144,  116 

Instruments 79   81,86,  146 

Instrumental  Supports 54 

Internal  Abdominal  Ring 39 

Irreducible  Hernia 59,  103 

Ischiatic 2,  119 

J. 

Jameson,  H.  G 137 

Jobert,  I.  A 145 

K. 

Kangaroo  Tendon   172,  197 

Keetley,  C.  B 187 


—  245   — 

PAGES. 

Kingdon's  Table 9 

Knife,  Hernia 79,     82 

L. 

Langenbeck,  C.  J.  M 132 

Lawrence,   VV g8,  123,  132 

Leisrink    H.  W 204 

Ligament,  Gimbernat's 36,  95 

Poupart's 37,  45,  46,  89,  91,  105 

Triangular 39 

Ligature,  Animal 165,  218,  229,  231 

Linea  Alba 36 

Lister,  Joseph,  Sir 165 

Lucas,  C 192 

M. 

Mackif",  J.  H 213 

Macewen,  Wm 197 

Malgaigne,  M 4,  8 

McBurney,  Charles 208 

MacCormar,  W 193 

McGillicuddy,  T.J 207 

Mesentery 12 

Muscle,  Cremaster. 21,  43 

External  Oblique 35.  37 

Internal  Oblique 38 

Transversalis 38,  39 

Monks,  G.  H 211 

N. 

Nationality  as  Affecting  Hernia ....  9 

Neck  of  Sac 26,  64,   75,   105,  218 

Needle,  Hernia,  Dovvell's,    G 158 

"        Marcy's,  H.  0 86 


—  246  — 

PAGES. 

Needle,  Hernia,  Wood's,  J 149 

"         Wood's,  T 147 

O. 

Oblique  Inguinal  Hernia 48 

Obturator  Artery 94,  113 

Hernia 113 

Obre 117 

Occupation  as  Affecting  Hernia 9,  220 

Omentum,  Removal  of 75,  81,  97,  117,  125 

Operation  for  Cure  of  Hernia     78,  85, 103,  124,  175,  222 

Advantages  of  the  Open  Method,  167,  174,  222,  230 

Conditions  Rendering  Advisable 72,   103,  214 

In  Children.   214 

Adults 220 

Details  of  Open  Method 79,   105,  236 

Operators,  See  List  of 

Operative  Measures 72,  79,  85,   103,  214,  236 

OPERATORS — THE   OPEN    WOUND    METHOD:       EUROPE. 

Alexander,  William 193 

Annandale,  Thomas,  Prof 176 

Andaregg ig8,  204 

Banks,  W.  Mitchell 182 

Barker,  Arthur 186 

Bassini,   Prof 202 

Buchanan,  George 193 

Championniere,  L 182 

Cousens,  Ward 197 

Czerney,  V.  Prof 177 

Franks  Kendal 184 

H  ardie,  James 1 84 

Heath,  Christopher 187 

Heuston,  F.  T 196 


—  247  — 

Langenbeck,  C.  J.  M ^^^^^' 

Leisrink.   H.  W ' ^^^ 

Lucas,  Clement ^°"* 

Mac  Cormac,  Wm ^^^ 

Macewen,  Wm '. ^^^ 

Poland,  John .....'.*. ....[....[ ^^^ 

Puzey,  Chauncey ^^^ 

Rabagliati,  A V. ^^^ 

Riesel.  Otto ' ^^^ 

Robinson,  A.  W ^°^ 

Shede,  Max ^.. ^^^ 

Schumucker ^^^ 

Socin,  Prof '  *  *  *    ^^2 

Spanton,  W.  D.  . .  ^^^ 

Steele,  Charles .'.'.'.'.".*.*.'.'.' ^'°'  ^'^ 

Stoker,  W.  P \ '^^ 

Stokes,  Wm ^^^ 

Svenson ^^3 

Treves.  F. . .  .....*.*  *.''.'.'.' ^°5 

Tilanus,  J.  W.  R..  Prof. ^^^ 

Walsham,  W.  J ^^^ 

Wells,  Spencer •'   ^^i 

Wright,  G.  A ;;; ^'^'  ^38 

Wood,  John : ^^^ 

84,  109,   148 

IN   AMERICA. 

Allen,  Dudley  P 

Bradford,  E    H.  ......  ^ '  .'.^ ^^° 

Birchard.  T.  H....  ^°^ 

Burrell,   H.  L ............[ ^°^ 

Cushing,  H.  W ^" 

Dowell,  G ^" 

Gay,  G.  W ^^^ 

Hamilton,  John  B. ^^° 

206 


—   248  — 

PAGES. 

Mackie,  J.   H 213 

McBurney,  Charles. . .    208 

McGillicuddy,  T.J 207 

Monks,  G.  H 211 

Pilcher.  L.  S   212 

Storer,  H.  R 12& 

Van  Der  Veer,  A 213 

Weir,  Robert 208 

Whitman,   R 211 

Wilcox,  D.  G 213 

Wilson,  A.  H 70 

P. 

Paletta 22 

Pancoast,  Joseph 144 

Peritoneal  Pouch 21,  49,  97,  loS,   222,  224 

Obliteration  of too,  108 

Sac 19,  50,   77,  86,  107 

Peritoneum 15,25,49,  224 

Changes  in 16,  25,   30 

Elongation  of 18,   28 

Pilcher,  L.  S 206,  212 

Poland,  John " 195 

Poupart's  Ligament 37,  45,  48,   89.   91,  105 

Pott,  Percival 129 

Processus  Vaginalis 2i 

Punctum  Aureum 129 

Puzey,  Chauncy 1 87 

Q. 

Quercus  Alba 145 

R. 

Rabagliati,  A 188 


—  249  — 

FASES. 

Radical  Cure  of  Inguinal  Hernia 79.  220»  228 

Femoral  Hernia I03.  232 

Obturator  Hernia ^^5 

Umbilical "4,  234 

Resum6 ^^^ 

Riesel,Otto 2°^ 

Ring  Closure  by  Use  of  Catgut  or  Tendon  Suture.  .86,  108,  174 

218,  228,  237 

Wire 109.   M9 

External  Abdominal 3^,  80.  104 

Femoral  or  Crural 93.97.  108   . 

Internal  Abdominal 39.  81,     96 

Pillars  of 35,  104.  151.  201,  222 

Royal  Suture ^^9 

Robinson.  A.  W ^^^ 

S. 

Sac,  Adhesions  of 27,  30,     59 

Changes  in 25,27,30.     68 

Contents  of 66,  68,  81,  98,  113,  121 

Disposition  of 76,84,105,125,177,189,  237 

Formation  of U,  19.  23,  77,   105 

Saphenous  Opening 89   92,   108 

Scarpa.H 23,  115 

Schede,  Max ^77 

Schreger.  B.  G 22 

Scrotal  Hernia 50,     62 

Seller.  B.  G ^^ 

Septum  Crurale 94,     97 

Seton,  Use.  as  a  Cure '39 

Sex,  as  affecting  Hernia 8,  220 

Schumucker '32 

Sigmoid  Flexure '3 

Simmons.  P.  G '72 


-  -.V  —    250    — 

PAGES. 

Socin,  Prof 178,  181 

Spanton,  W.  D 216 

Spermatic  Artery 43 

Cord 42,  94 

Vein 43 

Steele,  Charles , 176 

Stoker,  W.  P 195 

Stokes,  W.  Prof 193 

Storer,  H.  R 126 

Sutures,  Catgut 108.  165,  185,  190,  196,  235 

Silk 177,  186 

Tendon 85,  125,  161,  174,  182,  218,  235 

Wire. 109,  149.  154,  158,  163 

Swenson 199,  205 

Symptoms  of  Inguinal  Hernia 48 

Femoral  Hernia loi 

Obturator  Hernia 114 

Strangulated  Hernia 64 

Umbilical  Hernia 120 

T. 

Tables 3.  5,  6,  7,  9,  181 

Taxis 73 

Transversalis  Fascia 39 

Muscle 38 

Treatment  of  Wound 83,  85,  218,  237 

Treves,  F * 188 

Tilanus,  J.  W.  R 182 

Torsion  of  Sac 193 

Trusses,  Adjustment  of 56 

Difficulty  of  Retaining  in  Children 216 

Kinds  of 57 

Stagner 57 

Wood-pad 138 


—  251  — 

PAGES, 

Tunica  Vaginalis 21 

U. 

Umbilical  Hernia 120,  234 

V. 

Van  Der  Veer,  A 213 

Vas  deferens 42,  43 

Ventral  Hernia 127,  236 

Velpeau,   M 144 

W. 

Walsham.  W.  J.,  Mr ig7 

Warren,  J.  Collins 134 

Warren,  Joseph  H 82.   145 

Watson,  J J4- 

Weir,  Robert 20S 

Welsch,  G 118 

Wells,  Spencer,  Sir 216,   238 

White,  H.  C '126 

Whitman,   R 211 

Wilcox,  D.  G 213 

Wilson,  A.  H 70 

Wood  John 109.  148,   189 

Wood  Thomis 147 

Wright,  G.  A 188 

Wutzer I  gq 

Wyman,  Jeffreys 165 

Y. 

Young,  Thomas 170 

Z. 

Zimmermann 24 


COMPARATIVE 

DIGESTIVE  POWER  OF  PEPSINS, 


R.  H.  Chittenden,  Ph.  D.,  Professor  of  Physiological  Chemistiy  at  Yale  Uni- 
versity, in  a  paper  on  Digestive  Ferments,  read  before  the  New  York  Academy  of 
Medicine,  January  23,  1889,  and  published  in  the  Philadelphia  Medical  News, 
February  16,  1889,  says : 

"As  a  final  result,  then,  we  may  consider  the  true  proteolytic  power  of  the 
folio-wing  pepsin  compared  with  one  of  the  highest  digestive  power  to  be  as  foUows: 

Relative 

Proteolytic 

Action. 

1  Parke,  Davis  &  Co-'s  Pepslnum  Purum  in  Lamellis    100 

2  Fairchild's  Pepsin  in  Scale 52 

3  Scheffer's  Dry  Pepsin,  Concentrated 48 

4  Jensen's  Crystal  Pepsin 35 

5  Ford's  Pepsin  in  Scales 32 

6  North's  Pure  Pepsin 16 

7  Boudaulfs  Pepsin 14 

8  Royal  Chemical  Co. 's  Pure  Pepsin 0 

Other  eminent  investigators  haye  reached  the  same  results  as  to  the  pepsin  of 
the  highest  digestive  power. 

We  will  leave  physicians  to  draw  their  own  conclusions  as  to  what  pepsin  to 
prescribe,  from  the  facts  above  submitted. 

Reprints  of  this  and  other  articles  relating  to  the  quality,  incompatibilities  and 
therapeutic  application  mailed  to  physicians  on  request. 


GLTOEEm    SUPPOSITORIES. 

{Suppositoria  Olycerini,  Suppositoria  Aperitiva.) 

(Containing  95  per  cent,  of  Glycerin.) 

A    CONVENIENT    METHOD    OF    TREATING    CONSTIPATION. 

This  ready  means  of  securing  defecation  is  likely  to  become  very  popular.  It  i« 
a  great  improvement  over  the  injection  of  glycerin,  and  quite  as  efficacious. 

To  those  physicians  who  have  not  employed  them  we  commend  their  early  trial, 
and  to  this  end  we  will  furnish  samples  free  on  request. 

In  prescribing,  we  ask  physicians  who  desire  to  use  a  reliable,  active  product  to 
specify  glycerin  suppositories  of  our  manufacture. 


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